ECMO–Bridged Versus Elective LVAD Implantation: Comparable Long-Term Survival and Quality of Life in a 13-Year Single-Center Cohort

Background and Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an established rescue therapy for refractory cardiogenic shock. When weaning fails, urgent left ventricular assist device (LVAD) implantation under ongoing VA-ECMO support (a bridge-to-bridge strategy) is often the only path to survival. Whether this trajectory compromises long-term outcomes and quality of life (QoL) is unclear. Building on our group’s previous report in a smaller institutional cohort, we now compare long-term survival and QoL between VA-ECMO-bridged and elective LVAD recipients in an expanded cohort with extended follow-up. Materials and Methods: We retrospectively analyzed all adult LVAD implantations at our institution between January 2012 and December 2024. Patients were grouped by urgency: VA-ECMO-bridged (urgent LVAD under ongoing VA-ECMO support) or elective (LVAD without prior mechanical circulatory support). LVAD or mechanical circulatory support device exchanges, post-cardiotomy cardiogenic shock, and pediatric cases were excluded. Survival was analyzed with the Kaplan–Meier method and the log-rank test. Quality of life was assessed prospectively with the EuroQol-5D-5L visual analogue scale and the Patient Health Questionnaire-9 at 3, 6 and 12 months and at the most recent follow-up. Results: Of 97 LVAD recipients, 38 (39%) were VA-ECMO-bridged, and 59 (61%) were electives. The bridged cohort was numerically younger (53.9 ± 14.3 vs. 57.9 ± 11.8 years, p = 0.16), with no difference in sex (78.9% vs. 88.1% male, p = 0.21) or etiology. Intensive care and hospital stays were significantly longer in the bridged group (33.6 vs. 12.6 days, p = 0.029; 58.1 vs. 32.8 days, p = 0.041). Crude mortality at last follow-up was 31.6% (12/38) versus 55.9% (33/59) over 37.5 ± 23.9 vs. 48.8 ± 38.0 months of follow-up; Kaplan–Meier survival did not differ between groups (log-rank p = 0.2310, 95% CI). Quality-of-life questionnaires were completed by 53 of 97 patients (54.6%). EQ-5D-5L visual analogue scale scores improved over the first year in both groups and were equivalent at last follow-up (66.9 ± 20 vs. 65.2 ± 20, p = 0.879); PHQ-9 indicated only mild depressive symptoms in both groups at long-term follow-up (6.0 ± 4.6 vs. 5.4 ± 5.2, p = 0.676). Conclusions: Among patients who survive LVAD implantation, VA-ECMO bridging was not associated with worse long-term survival or quality of life than elective LVAD, despite a markedly longer index hospitalization. This data should be read as showing acceptable outcomes in selected survivors rather than equivalence of an intention-to-bridge strategy, since patients who die on VA-ECMO before LVAD are not captured. Patient selection, rather than urgency itself, appears to drive outcomes.