Advanced mechanical circulatory support for post-cardiotomy cardiogenic shock: a 20-year outcome analysis in a non-transplant unit

Abstract

BackgroundPost-cardiotomy cardiogenic shock (PCCS) has an incidence of 2–6 % after routine adult cardiac surgery. 0.5–1.5 % are refractory to inotropic and intra-aortic balloon pump (IABP) support. Advanced mechanical circulatory support (AMCS) can be used to salvage carefully selected number of such patients. High costs and major complication rates have lead to centralization and limited funding for such devices in the UK. We have looked the outcomes of such devices in a non-transplant, intermediate-size adult cardiothoracic surgery unit.MethodsInclusion criteria included any adult patient who had received salvage veno-arterial extra-corporeal membrane oxygenation (V-A ECMO) or a ventricular assist device (VAD) for PCCS refractory to IABP and inotropic support following cardiac surgery from April 1995-April 2015.ResultsSixteen patients met the inclusion criteria. Age range was 34–83 years (median 71). There was a male predominance of 12 (75 %). Overall, 15 (94 %) had received ECMO of which, 10 (67 %) had received central ECMO and 5 (33 %) had received peripheral ECMO. One patient (6 %) had a VAD. The most common complication was haemorrhage. Stroke, femoral artery pseudo-aneurysm, sepsis and renal failure also occurred. Thirty-day survival was 37.5 %. Survival rate to hospital discharge was 31.2 %. All survivors had NYHA class I-II at 24 months follow-up.ConclusionsOur survival rate is similar to that reported in several previous studies. However, the use of AMCS for refractory PCCS is associated with serious complications. The survivors in our cohort appear to maintain an acceptable quality of life.

Nursing care protocol for patients with a ventricular assist device

“…In relation to the importance of the hemodynamic monitoring, HR, MAP, CO, SvO 2, and pulse oximetry are widely discussed data in the literature (4,6) aiming at obtaining accurate data from critical patients using a VAD, corroborating the positive consensus of the experts in this study. However, the verification of the pulse, urine output, and temperature also presented favorable consensus among the experts.…”

“…Searches in the scientific literature (4)(5)(6)(7)(8)(11)(12)(13)(14)(15)(16) were conducted for the elaboration of the protocol and to carry out the discussion of the variables related to the patient using a ventricle assist device.…”

“…Long-term VADs are those surgically implanted and designed to increase the lifespan and/or as a bridge for transplantation. Moreover, VADs may be used to support the deficit of the right ventricle, left ventricle, or both (4) . The main function of VADs consists in ensuring an effective systemic perfusion, avoiding multiple organs dysfunction, providing improvement of the cardiac output and pulmonary edema, reducing the central venous pressure, and reducing the neurohormonal activity activated by the HF.…”

“…Ischemia is one of the most common causes of decompensated HF as it causes a reduction in the myocardial contractility (2) . Patients with HF presenting hemodynamic instability require periodical hospitalizations in order to improve their clinical condition through the use of inotropic agents and mechanical circulatory support (MCS), such as ventricular assist devices (VADs) (4) . There are different types of VADs, such as percutaneous VADs, which are indicated for short-term use and may be inserted in the laboratory through the use of catheters, as a strategy to stabilize patients with acute cardiogenic shock.…”

Contemporary applications of intra-aortic balloon counterpulsation for cardiogenic shock: a “real world” experience

“…However, a more accurate classification is needed. Postcardiotomy shock has an incidence of 2-6% after cardiac surgery, but only 0.5-1.5% are refractory to inotropic and IABP therapy (16,17). While refractory postcardiotomy shock carries a dismal prognosis without MCS systems ensuring full cardiac function replacement, more uncertainty exists as regard to its not-refractory presentation.…”