Impact of preoperative hemodynamic support on early outcome in patients assisted with paracorporeal Thoratec® ventricular assist device

Abstract

Background: Mechanical circulatory support has become a well-established procedure for some patients with cardiogenic shock. However, patient selection and timing of implantation remains critical. This retrospective study was undertaken to identify preoperative predictors of survival in ICU of patients requiring mechanical circulatory support. Methods: Between 1996 and 2006, 71 patients (61 men, 10 women, aged 41.6 AE 12.2 years) with primary cardiogenic shock were assisted using the paracorporeal Thoratec W VAD. Twenty-seven (38%) patients needed preoperative mechanical ventilation. Preoperative IV hemodynamic drug support included dobutamine in 63 (89%), vasopressors (adrenaline, noradrenaline or dopamine !5 mg/kg min) in 47 (66%), and intraaortic balloon counter-pulsation in 22 (31%) patients. Mean preoperative blood creatinine and total bilirubin levels were 162.2 AE 72.4 mmol/l and 36.4 AE 53.9 mmol/l, respectively. Results: Fifty-six (79%) patients required biventricular and 15 (21%) left ventricular support. Patients were assisted for a mean duration of 73.1 AE 93.6 days (extremes, 1-480 days). Twenty-five patients (35%) died while on support. Among these, 18 patients (25%) never recovered sufficiently to allow dismissal from ICU, and died after a mean of 15.4 AE 14.3 days. Logistic regression identified preoperative IV adrenaline as sole predictor for ICU death (OR, 5.48; 95% CI,, p = 0.012). Conclusions: The need for preoperative IV adrenaline therapy appeared to be the sole independent risk factor for death in ICU in patients assisted with the Thoratec W paracorporeal VAD. This suggests that, besides hemodynamic and metabolic consequences of cardiogenic shock, preoperative activation of the inflammatory cascade could influence the prognosis of patients undergoing mechanical circulatory support. #

Thoratec implantable ventricular assist device: The Papworth experience

“…The 71% successful bridge to transplant rate in this series is similar to that reported previously in the Thoratec IVAD multicenter trial (69%). 13 It is also comparable to the success rate reported with other pulsatile devices, such as the Thoratec PVAD (65%), 17 the HeartMate IP LVAD (71%), 6 and the HeartMate VE (LVAS, 71%). In this series, patients who required biventricular support at the time of LVAD implant had a lower survival (60%), consistent with previous studies demonstrating that patients with increased severity of illness, especially with renal and hepatic failure, are more likely to require BVADs and thus be at a higher risk of death than patients requiring LVAD alone.…”

Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients

“…However, the use of catecholamines in acute heart failure may be associated with higher short-and long-term mortality [5,6]. Among catecholamines, retrospective analyses have linked the need for epinephrine to worse outcome in patients with myocardial infarction or treated with mechanical circulatory support [7,8]. More recently, data from a prospective patient cohort [9] and two small randomized trials [10,11] suggest that in cardiogenic shock, epinephrine might be associated with detrimental short-term outcome.…”

Impact of Preoperative Percutaneous Cardiopulmonary Support on Outcome Following Left Ventricular Assist Device Implantation

“…Kirsch et al were more aggressive in utilizing mechanical right ventricular support in patients who underwent LVAD implantation, and 79% of their patients received mechanical right ventricular support. 16 As shown in Table 5, patients who required preoperative PCPS developed right ventricular failure more frequently (36% vs. 15%, P=0.0431) and their total bilirubin level was higher (3.4±5.8 mg/dl vs. 1.6±2.3 mg/dl, P=0.0276) at 1 month after LVAD implantation as compared with patients without preoperative PCPS. These results indicate that some patients who initially required PCPS developed right ventricular failure and hepatic failure after LVAD implantation, which may have been the reasons for the worse survival in patients with preoperative PCPS.…”