Preoperative patient optimization using extracorporeal life support improves outcomes of INTERMACS Level I patients receiving a permanent ventricular assist device†

Abstract

Preoperative patient optimization using ECLS improves outcomes of INTERMACS Level I patients receiving a permanent VAD.

Ventricular Assist Device in Acute Myocardial Infarction

“…Similarly, in patients who have refractory shock and are potential LVAD candidates, stabilization of end-organ function and correction of metabolic derangements with ECMO prior to durable LVAD implantation can improve post-LVAD survival (12,13). This strategy can be attractive because TCS is less invasive and resource-intensive than durable LVAD, stabilization by TCS allows time for a more detailed assessment of LVAD/transplant candidacy, and patients who do not survive or stabilize with an adequate support TCS device, such as ECMO, are unlikely to have benefitted from LVAD (13).…”

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012

“…Current 2 -3-year survival rates in carefully selected patients receiving the latest continuous flow devices are excellent, and comparable to early survival after heart transplantation. 595 However, fewer data are available Despite technological improvements, bleeding, thromboembolism (both of which can cause stroke), pump thrombosis, driveline infections and device failure remain significant problems and affect the long-term outcome of patients on MCS. 599,603 -606 It is recommended that such devices should only be implanted and managed at centres with appropriately trained specialist HF physicians and surgeons and an outpatient LVAD clinic with trained nursing staff.…”

Current Practice in Patient Selecting for Long-Term Mechanical Circulatory Support

“…As mentioned earlier, the early mortality in this group was 38 % compared with profiles 3 and 4 at 11 % (hazard ratio 2.7) and profiles 1 and 2 had significantly higher incidences of liver injury (39 vs 11 %) [8]. As Stevenson et al described, even though the outcomes are worse in patients with profiles 1 and 2, INTERMACS shows that we are still continuing to implant LVADs in these levels of patients [ [34]. Although INTERMACS profile level shows difference, when looking at the acuity at implantation level, whether it was done emergently or done electively, there was some similarity.…”

“…In late 2013, the Centers for Medicare and Medicaid Services (CMS) updated the National Coverage Determination (NCD) to consider patients for LVAD therapy that met specific criteria at the time of implantation, thereby providing strict guidelines to designate patients into the categories of BTT or DT only [34]. It should be noted that the designation at time of implant is an exercise in predicting the future and thus an imperfect science at best and the artificial designations of at least a third of patients into these categories in nearly impossible [27,28].…”