Continuous-Flow Left Ventricular Assist Device Therapy in Patients With Preoperative Hepatic Failure: Are We Pushing the Limits Too Far?

Abstract

The purpose of this study was to evaluate the effects and outcome of continuous-flow left ventricular assist device (cf-LVAD) therapy in patients with preoperative acute hepatic failure. The study design was a retrospective review of prospectively collected data. Included were 42 patients who underwent cf-LVAD implantation (64.3% HeartMate II, 35.7% HeartWare) between July 2007 and May 2013 with preoperative hepatic failure defined as elevation of greater than or equal to two liver function parameters above twice the upper normal range. Mean patient age was 35 ± 12.5 years, comprising 23.8% females. Dilated cardiomyopathy was present in 92.9% of patients (left ventricular ejection fraction 17.3 ± 5.9%). Mean support duration was 511 ± 512 days (range: 2-1996 days). Mean preoperative laboratory parameters for blood urea nitrogen, serum creatinine, total bilirubin, and alanine aminotransferase were 9.5 ± 5.4 mg/dL, 110.3 ± 42.8 μmol/L, 51.7 ± 38.3 mmol/L, and 242.1 ± 268.6 U/L, respectively. All parameters decreased significantly 1 month postoperatively. The mean preoperative modified Model for Endstage Liver Disease excluding international normalized ratio score was 16.03 ± 5.57, which improved significantly after cf-LVAD implantation to 10.62 ± 5.66 (P < 0.001) at 7 days and 5.83 ± 4.98 (P < 0.001) at 30 days postoperatively. One-year and 5-year survival was 75.9 and 48.1%, respectively. 21.4% of the patients underwent LVAD explantation for myocardial recovery, 16.7% were successfully transplanted, and 7.1% underwent LVAD exchange for device failure over the follow-up period. Patients with preexisting acute hepatic failure are reasonable candidates for cf-LVAD implantation, with excellent rates of recovery and survival, suggesting that cf-LVAD therapy should not be denied to patients merely on grounds of "preoperative elevated liver enzymes/hepatopathy."

Successful continuous-flow left ventricular assist device implantation with adjuvant tricuspid valve repair for advanced heart failure

“…In addition, this initial temporary cholestasis resulting from RV dysfunction has been documented previously 2. Although laboratory parameters tend to normalise with successful cf-LVAD implantation, the effect appears to dissipate over time.…”

“…In a previous study, 33.4% of patients experienced RVF postoperatively and 10–15% required RV support 2,5. RVF after cf-LVAD implantation is occasionally unavoidable in a deteriorated heart.…”

“…The incidence of RVF in this population ranges from 10 to 50% and is a risk factor for peri-operative and postoperative mortality and morbidity in patients undergoing cf-LVAD implantation 2,4,5…”

“…HeartMate II may transiently worsen the right ventricular function in the initial post-implant period because of a higher cardiac output resulting in increased venous return and right ventricular preload 2. In addition, this initial temporary cholestasis resulting from RV dysfunction has been documented previously 2.…”

“…The use of implantable mechanical circulatory support devices, such as cf-LVAD, has increased in recent years 2. Safer long-term cf-LVAD support has been achieved because of improved outcomes 1.…”