Predictors of mid-term outcomes in patients undergoing implantation of a ventricular assist device directly after extracorporeal life support

Tsyganenko, Dmytro; Gromann, T.; Schoenrath, Felix; Mueller, Marcus; Mulzer, Johanna; Starck, Christoph; Krabatsch, Thomas; Stein, Julia; Falk, Volkmar; Potapov, Evgenij

doi:10.1093/ejcts/ezy351

Cited by 28 publications

(30 citation statements)

References 28 publications

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“…We considered patients weanable from pVA‐ECMO without transition to dMCS if they met the following criteria during a weaning trial, that is, clamped ECMO circuit for 1 min: cardiac index ≥2.4, central venous pressure ≤18 mm Hg, PCWP ≤18 mm Hg, and a LV ejection fraction >30% with minimal inotropic support (≤0.02 µg/kg/min epinephrine or equivalent). Available studies describing implantation of dMCS following short‐term mechanical circulatory support for cCS, including pVA‐ECMO, showed preimplant hemodynamic data in good agreement with our weaning criteria …”

Section: Methodssupporting

confidence: 82%

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Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

et al. 2019

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Peripheral veno‐arterial extracorporeal membrane oxygenation (pVA‐ECMO) has gained increasing value in the management of patients with critical cardiogenic shock (cCS), allowing time for myocardial recovery. Failure of myocardial recovery has life‐altering consequences: transition to durable mechanical circulatory support (dMCS), urgent heart transplantation, or withdrawal of support. Clinical factors controlling myocardial recovery under these circumstances remain largely unknown. Using a retrospective cohort, we developed a model for early prediction of transition to dMCS in patients undergoing pVA‐ECMO for cCS. To promote myocardial recovery, our clinical management centered around left ventricular pressure unloading, that is, targeting pulmonary capillary wedge pressures (PCWP) ≤18 mm Hg. We collected demographic data, laboratory findings, inotrope use, and two‐dimensional transthoracic echocardiography measurements, all limited to the first 72h of pVA‐ECMO (D1‐3). Out of 70 patients who were alive after pVA‐ECMO, 27 patients underwent implantation of dMCS. There was no significant difference in survival to hospital discharge between patients with or without transition to dMCS. Ejection fractionD1‐3 (per 10% increase, OR 0.37 [0.17‐0.79]) and amount of inotropic supportD1‐3 (OR 4.77 [1.6‐14.18]) but neither myocardial wall tension nor PCWP emerged as significant predictors of transition to dMCS. Optimism‐corrected c‐index (0.90 [0.89‐0.90]) revealed an excellent discriminative ability of our model. In summary, our model for early prediction of transition to dMCS in patients with cCS undergoing pVA‐ECMO identifies indicators of inotropic state as relevant factors. Absence of markers for myocardial oxygen consumption or left ventricular pressure loading allows us to hypothesize sufficient cardiac unloading in our cohort with PCWP‐targeted management.

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Section: Methodssupporting

confidence: 82%

“…Available studies describing implantation of dMCS following short-term mechanical circulatory support for cCS, including pVA-ECMO, showed preimplant hemodynamic data in good agreement with our weaning criteria. [14][15][16]…”

Section: Clinical Managementmentioning

confidence: 99%

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

et al. 2019

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“…Between 01/2012 and 01/2018 in our institution 714 patients were supported with ECLS. Patients who underwent long-term LVAD implantation after hemodynamic stabilization on ECLS present 62% 30-day survival and 43% one-year survival, which is acceptable in the setting of severe cardiogenic shock (18).…”

Section: Discussionmentioning

confidence: 99%

Temporary mechanical circulatory support for refractory heart failure: the German Heart Center Berlin experience

Nersesian¹,

Hennig²,

Müller³

et al. 2019

Ann. Cardiothorac. Surg.

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Background: Temporary mechanical circulatory support (MCS) offers a valuable option for treatment of refractory heart failure. We present our experience with selected MCS devices in cardiogenic shock of different etiologies. Methods: We retrospectively studied patients who were treated in our institution between 01/2016 and 07/2018. Patients receiving only veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support were excluded. Left ventricular support patients received Impella; right ventricular support was conducted using Levitronix CentriMag. Results: Thirty-seven patients received an Impella left ventricular assist device (LVAD). Etiology was: acute on chronic ischemic cardiomyopathy (ICMP; n=12), acute myocardial infarction (AMI; n=11), dilated cardiomyopathy (DCMP; n=7) and toxic cardiomyopathy (TCMP; n=2). Two patients presented with postcardiotomy shock and acute myocarditis, respectively. In one case, Takotsubo cardiomyopathy was diagnosed. Impella was used solely in 28 patients (Impella group) with an in-hospital survival of 37%. In nine patients, Impella was used in combination with extracorporeal life support (ECLS) implantation (ECMELLA group)-in-hospital survival was 33%. In the Impella group six patients recovered, six received a long-term VAD and 16 died on device. In the ECMELLA group one patient recovered, three received a long-term VAD and five died. The majority of CentriMag implantations as a right ventricular assist device (RVAD) were necessary after LVAD implantation (n=52); of these patients, 14 recovered, eight received long-term VAD and 30 died. The remaining 17 patients were supported by RVAD due to AMI (n=7); postcardiotomy (n=7); right heart failure after heart transplantation (n=2) and ICMP (n=1). Six of these patients recovered, two required long-term VAD and nine died. Conclusions: Survival after MCS implantation for left as well as right heart failure in cardiogenic shock remains low, but is superior to that of patients without mechanical support. Short-term MCS remains an option of choice if right, left or biventricular support is needed.

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“…Despite end‐organ stabilization by ECLS Implantation prior to LVAD implantation, survival rates of this subpopulation 9 are still limited. To this regard, Tsyganenko et al 10 reporting the outcomes of 100 patients, bridged to LVAD implantation with an ECLS showed a 2‐year survival rate of 37.1%. In our series roughly one‐fifth of patients underwent HVAD implantation while on ECLS, thus considering the preoperative setting our results are in line with those reported in the literature.…”

Section: Discussion and Conclusionmentioning

confidence: 99%

Long‐term follow‐up of patients supported with the HeartWare left ventricular assist system

et al. 2020

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The aim of the present study is to report our long‐term experience with the HeartWare Ventricular Assist System (HVAD). Between July 2009 and February 2018, a total of 103 patients (mean age 50.0 ± 14.4, range 28‐74 years; 22 females) received HVAD implantation in a single center institution. A total of 26 (25.4%) patients were in cardiogenic shock preoperatively and received extracorporeal life support (ECLS) prior to HVAD implantation. The aim of left ventricular assist device (LVAD) implantation was bridge to transplantation (BT) in 59 (57.3%), destination therapy (DT) in 28 (27.2%), and bridge to decision in 16 (15.5%). There were 211.1 total patient years of support. Mean survival was 2.05 ± 2.14 years. Kaplan‐Meier analysis showed an overall survival rate of 69.7%, 56.7%, 46.0%, and 25.0% at 1, 2, 4, and 8 years, respectively. A total of 23 patients (22.3%) died during the hospital stay. Of them 65.2% (15 patients) were preoperatively in cardiogenic shock (INTERMACS 1). Sub‐analysis of the BT patients showed a mean survival of 2.45 ± 2.29 years with a survival rate of 85.1%, 75.1%, 67.2%, and 44.8% at 1, 2, 4, and 8 years, respectively. Among them, 20 patients received heart transplantation on follow‐up. Mean survival of DT patients was 2.18 ± 1.91 years with a survival rate of 67.9%, 49.0%, and 25.1% at 1, 2, and 4 years, respectively. At latest follow‐up in September 2018, 26 patients (25.24%) were still on LVAD. A total of five patients completed 6 years on LVAD, of them two were supported over 8 years. The most common adverse event reported was gastrointestinal bleeding requiring rehospitalization (0.161 EPPY). A total of 19 patients reported disabling stroke. Pump thrombosis was diagnosed in six patients (5.8%) (0.02 EPPY), of them four patients underwent pump exchange. To the best of our knowledge, this is the longest experience with HVAD reported so far. Patients supported with an HVAD show a satisfactory long‐term survival. Further multicenter evaluations are needed to confirm these single‐center results.

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Predictors of mid-term outcomes in patients undergoing implantation of a ventricular assist device directly after extracorporeal life support

Cited by 28 publications

References 28 publications

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

Temporary mechanical circulatory support for refractory heart failure: the German Heart Center Berlin experience

Long‐term follow‐up of patients supported with the HeartWare left ventricular assist system

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