A Decade of Short-Term Outcomes in Post–Cardiac Surgery Ventricular Assist Device Implantation

Age-Related Quality of Life in Cardiac Surgical Patients with Extracorporeal Life Support

BACKGROUND

 The rationale of the study was to analyze the impact of age on quality of life (QoL) in patients who had undergone cardiac surgery with consecutive extracorporeal life support (ECLS) treatment.

METHODS

 The study population consisted of 200 patients, operated upon between August 2006 and December 2018. The patient cohort was divided into two groups following an arbitrary cutoff age of 70 years. Comparative outcome analysis was calculated utilizing the European Quality of Life-5-Dimensions-5-Level Version (EQ-5D-5L).

RESULTS

 A total of 113 patients were 70 years or less old (group young), whereas 87 patients were older than 70 years (group old). In 45.7% of cases, the ECLS system was established during cardiogenic shock and external cardiac massage. The overall survival-to-discharge was 31.5% (n = 63), with a significantly better survival in the younger patient group (young = 38.9%; old = 21.8%, p = 0.01). Forty-two patients (66%) responded to the QoL survey after a median follow-up of 4.3 years. Older patients reported more problems with mobility (y = 52%; o = 88%, p = 0.02) and self-care (y = 24%; o = 76%, p = 0.01). However, the patients' self-rated health status utilizing the Visual Analogue Scale revealed no differences (y = 70% [50-80%]; o = 70% [60-80%], p = 0.38). Likewise, the comparison with an age-adjusted German reference population revealed similar QoL indices. There were no statistically significant differences in the EQ-5D-5L index values related to sex, number of comorbidities, and emergency procedures.

CONCLUSION

 Despite the limited sample size due to the high mortality rate especially in elderly, the present study suggests that QoL of elderly patients surviving ECLS treatment is almost comparable to younger patients.

The intra-aortic balloon pump as a rescue device: Do we need to shift our strategy for cardiogenic shock rescue after cardiac surgery?

OBJECTIVE

The intra-aortic balloon pump (IABP) is widely used to rescue patients from complications following cardiac surgery. Given improvements in rescue strategies over the past decade, the appropriateness of IABP must be reexamined. This study assessed the risk factors, outcomes, and predictors of survival of rescue IABP placement.

METHODS

Patients receiving an isolated rescue IABP during or after cardiac surgery from 2012 to 2020 were studied. All adult patients undergoing cardiac surgery except transplantation and primary mechanical circulatory support (MCS) procedures were included.

RESULTS

Of 10,591 patients, 397 (3.7%) received a perioperative IABP, including 182 (45.8%) with rescue IABP placement. The indications for rescue IABP were postcardiotomy shock (n = 66; 36.3%), failure to wean off cardiopulmonary bypass (n = 58; 31.9%), myocardial ischemia (n = 30; 16.5%), cardiac arrest (n = 25; 13.7%), and ventricular arrhythmia (n = 3; 1.6%). The in-hospital failure to rescue rate was 17.6% (n = 32 of 182) with a 90-day survival of 80.8% and 1-year survival of 76.9%. The most common etiology of mortality was ongoing cardiogenic shock (61.9%; n = 26 of 42). IABP use for >4 days and cardiac arrest as an indication for IABP were risk factors for 1-year mortality (adjusted hazard ratio, 2.68 [95% confidence interval (CI), 1.31-5.50] and 2.69 [95% CI, 1.11-6.54], respectively).

CONCLUSIONS

Rescue IABP following cardiac surgery is associated with increased early and 1-year mortality. Prolonged IABP use beyond 4 days or cardiac arrest as an indication portended a significantly worse prognosis. Rescue IABP may not be the optimal first-line temporary MCS for all patients, as the level of support provided might not match the severity of cardiogenic shock. Alternative MCS strategies should be considered early.

Temporary Mechanical Circulatory Support after Cardiac Surgery

Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.

Diazoxide preserves myocardial function in a swine model of hypothermic cardioplegic arrest and prolonged global ischemia

OBJECTIVE

Adenosine triphosphate potassium sensitive channels provide endogenous myocardial protection via coupling of cell membrane potential to myocardial metabolism. Adenosine triphosphate potassium sensitive channel openers, such as diazoxide, mimic ischemic preconditioning, prevent cardiomyocyte swelling, preserve myocyte contractility after stress, and provide diastolic protection. We hypothesize that diazoxide combined with hyperkalemic cardioplegia provides superior myocardial protection compared with cardioplegia alone during prolonged global ischemia in a large animal model.

METHODS

Twelve pigs were randomized to global ischemia for 2 hours with a single dose of cold blood (4:1) hyperkalemic cardioplegia alone (n = 6) or with diazoxide (500 μmol/L) (n = 6) and reperfused for 1 hour. Cardiac output, myocardial oxygen consumption, left ventricular developed pressure, left ventricular ejection fraction, diastolic function, myocardial troponin, myoglobin, markers of apoptosis, and left ventricular infarct size were compared.

RESULTS

Four pigs in the cardioplegia alone group could not be weaned from cardiopulmonary bypass. There were no differences in myoglobin, troponin, or apoptosis between groups. Diazoxide preserved cardiac output versus control (74.5 vs 18.4 mL/kg/min, P = .01). Linear mixed regression modeling demonstrated that the addition of diazoxide to cardioplegia preserved left ventricular developed pressure by 36% (95% confidence interval, 9.9-61.5; P < .01), dP/dt max by 41% (95% confidence interval, 14.5-67.5; P < .01), and dP/dt min by 33% (95% confidence interval, 8.9-57.5; P = .01). It was also associated with higher (but not significant) myocardial oxygen consumption (3.7 vs 1.4 mL O2/min, P = .12).

CONCLUSIONS

Diazoxide preserves systolic and diastolic ventricular function in a large animal model of prolonged global myocardial ischemia. Diazoxide as an adjunct to hyperkalemic cardioplegia may allow safer prolonged ischemic times during increasingly complicated cardiac procedures.

Early Enteral Nutrition Tolerance in Patients With Cardiogenic Shock Requiring Mechanical Circulatory Support

Background: Enteral nutrition (EN) is recommended within the first 24-48 h for patients with hemodynamic stability, following admission to an intensive care unit (ICU). However, for patients with approximate stable hemodynamics requiring mechanical circulatory support and vasoactive drugs, the application of early EN remains controversial. We sought to evaluate the tolerance of early EN in patients with cardiogenic shock who required vasoactive drugs and mechanical circulatory support after cardiac surgery. Methods: This single-center, prospective observational study included patients with cardiogenic shock, requiring vasoactive drugs and mechanical circulatory support after cardiac surgery, undergoing EN. The primary endpoint was EN tolerance and secondary endpoints were mortality, length of mechanical ventilation, and length of ICU stay. Results: From February 2019 to December 2020, 59 patients were enrolled, of which 25 (42.37%) developed intolerance within 3 days of starting EN. Patients in the EN intolerant group had a longer median length of mechanical ventilation (380 vs. 128 h, p = 0.006), a longer median ICU stay (20 vs. 11.5 days, p = 0.03), and a higher proportion of bloodstream infections (44 vs. 14.71%, p = 0.018). The median EN calorie levels for all patients in the first 3 days of EN were 4.00, 4.13, and 4.28 kcal/kg/day, respectively. Median protein intake levels of EN in the first 3 days were 0.18, 0.17, and 0.17 g/kg/day, respectively. No significant difference was observed in the median dose of vasoactive drugs between the groups (0.035 vs. 0.05 μg/kg/min, p = 0.306). Conclusions: Patients with cardiogenic shock after cardiac surgery had a high proportion of early EN intolerance, and patients with EN intolerance had a worse prognosis, but no significant correlation was identified between EN tolerance and the dose of vasoactive drugs.

Postcardiotomy Extracorporeal Membrane Oxygenation: Narrative Review Navigating the Ethical Issues

Postcardiotomy shock (PCS) is an uncommon and life-threatening surgical complication. Extracorporeal membrane oxygenation (ECMO) is the first line of mechanical circulatory support for treating PCS when medical therapies are insufficient. Reaching a "therapeutic ceiling" or a "bridge to nowhere" is a common clinical scenario in which medical avenues for recovery have been exhausted. These situations pose emotional and ethical challenges for patients, their surrogates, and clinicians. To shed light on these ethically challenging situations in PCS and potential approaches, the authors conducted a narrative review of the literature. Publications were utilized to describe current trends in the diagnosis and management of the patient with PCS, with particular emphasis on the therapeutic ceiling for life support. Most of the recommendations came from practice parameters or expert opinions to support specific interventions. The authors proposed a stepwise multidisciplinary approach to reduce PCS-associated ethical and emotional challenges. Their proposed algorithm was based on the likelihood of the need for ECMO support based on the mortality risk stratification of cardiac surgery. They suggested focused discussions around the commencement of ECMO or other life-sustaining therapies-ideally preoperatively at the time of consent-through shared decision-making and, subsequently, proactive multidisciplinary education and updates to the surrogate decision-makers relying on realistic prognosis and consideration of the patient wishes during the ECMO run.

Venoarterial Extracorporeal Membrane Oxygenation for Postcardiotomy Shock-Analysis of the Extracorporeal Life Support Organization Registry

OBJECTIVES

Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

DESIGN

Analysis of extracorporeal life support organization registry from January 2010 to December 2018.

SETTING

Multicenter worldwide registry.

PATIENTS

Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

INTERVENTIONS

Venoarterial extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS

Hospital death, weaning from extracorporeal membrane oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane oxygenation. A significant trend toward more extracorporeal membrane oxygenation use in recent years (coefficient, 0.009; p < 0.001) was found. Mean age was 56.3 ± 14.9 years and significantly increased over time (coefficient, 0.513; p < 0.001). Most commonly, venoarterial extracorporeal membrane oxygenation was instituted after coronary artery bypass surgery (26.8%) and valvular surgery (25.6%), followed by heart transplantation (20.7%). Overall, successful extracorporeal membrane oxygenation weaning was possible in 4,520 cases (56.4%), and survival to hospital discharge was achieved in 41.7% of cases. In-hospital mortality rates remained constant over time (coefficient, -8.775; p = 0.682), whereas complication rates were significantly reduced (coefficient, -0.009; p = 0.003). Higher mortality was observed after coronary artery bypass surgery (65.4%), combined coronary artery bypass surgery with valve (68.4%), and aortic (69.6%) procedures than other indications. Lower mortality rates were observed in heart transplantation recipients (46.0%). Age (p < 0.001), central cannulation (p < 0.001), and occurrence of complications while on extracorporeal membrane oxygenation were independently associated with poorer prognosis.

CONCLUSIONS

The analysis confirmed increased use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.

Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support

Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.

30-Day perioperative mortality following venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in patients with normal preoperative ejection fraction

OBJECTIVES

Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h.

METHODS

Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization.

RESULTS

A total of 62 125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2-8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P < 0.001], major bleeding during VA-ECMO (OR 3.76; P = 0.001), prolonged cardiopulmonary bypass time (OR 1.01; P < 0.001) and female gender (OR 4.87; P < 0.001).

CONCLUSIONS

Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.

Investigating the cause of hemolysis in patients supported by a pulsatile ventricular assist device

A survey conducted by Abiomed, Inc. revealed that 10 of 60 patients who received ventricular assistance via the AB5000 ventricular assist device (VAD) experienced hemolysis. The present study was conducted to investigate which factors influence hemolysis under pulsatile-flow VADs such as the AB5000. We compared the specificity of the AB5000 and its driving console with those of the NIPRO-VAD and VCT50χ under severe heart failure conditions using a mock circulatory system with a glycerol water solution. We used the mock circuit with bovine blood to confirm which pump conditions were most likely to cause hemolysis. In addition, we measured the shear velocity using particle image velocimetry by analyzing the seeding particle motion for both the AB5000 and NIPRO-VAD under the same conditions as those indicated in the initial experiment. Finally, we analyzed the correlation between negative pressure, exposure time, and hemolysis by continuously exposing fixed vacuum pressures for fixed times in a sealed device injected with bovine blood. Applying higher vacuum pressure to the AB5000 pump yielded a larger minimum inlet pressure and a longer exposure time when the negative pressure was under - 10 mmHg. The plasma-free hemoglobin increased as more negative pressure was driven into the AB5000 pump. Moreover, the negative pressure interacted with the exposure time, inducing hemolysis. This study revealed that negative pressure and exposure time were both associated with hemolysis.

Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.

Sex Influence on Heart Failure Prognosis

Heart failure (HF) affects 1-2% of the population in developed countries and ~50% of patients living with it are women. Compared to men, women are more likely to be older and suffer hypertension, valvular heart disease, and non-ischemic cardiomyopathy. Since the number of women included in prospective HF studies has been low, much information regarding HF in women has been inferred from clinical trials observations in men and data obtained from registries. Several relevant sex-related differences in HF patients have been described, including biological mechanisms, age, etiology, precipitating factors, comorbidities, left ventricular ejection fraction, treatment effects, and prognosis. Women have greater clinical severity of HF, with more symptoms and worse functional class. However, females with HF have better prognosis compared to males. This survival advantage is particularly impressive given that women are less likely to receive guideline-proven therapies for HF than men. The reasons for this better prognosis are unknown but prior pregnancies may play a role. In this review article we aim to describe sex-related differences in HF and how these differences might explain why women with HF can expect to survive longer than men.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

Weaning-Related Shock in Patients With ECMO: Incidence, Mortality, and Predisposing Factors

OBJECTIVE

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) commonly is used to manage refractory cardiogenic shock after cardiac surgery, with 31% to 76% of patients successfully weaned off their ECMO. However, it is associated with high mortality rates, and 20% to 65% of weaned patients do not survive to hospital discharge. This study aimed to assess the incidence of ECMO weaning-related shock, the risk factors, and prognosis in the intensive care unit (ICU).

DESIGN

Retrospective observational cohort study.

SETTING

Surgical ICU of Cardiology Institute of Pitié-Salpêtrière University Hospital (Paris-France).

PARTICIPANTS

Patients who were assisted with a peripheral VA-ECMO from January 2015 to December 2017 were included. Patients with venovenous, central, or right ECMO were excluded.

MEASUREMENTS

The authors collected data on patients' characteristics, during and after surgery. The indications for VA-ECMO implantation were ventricular dysfunction, primary graft dysfunction, and refractory cardiac arrest. Weaning-related shock was defined as the need to introduce or increase the dose of catecholamine at ECMO explantation or in the following week.

RESULTS

After weaning off VA-ECMO, 56 of 146 patients (38.4%) presented weaning-related shock: 55% were septic shocks, 12.5 % were caused by right ventricle failure, and 7.1% by hemorrhage. ICU mortality was 42% versus 8% in patients who did not present shock. Multivariate analysis showed that patients with pulmonary hypertension and those with norepinephrine before weaning were more likely to develop shock.

CONCLUSION

ECMO weaning-related shock is frequent in patients with refractory cardiogenic shock after cardiac surgery. This is most commonly caused by sepsis and causes higher mortality rates, calling for further evaluation.

Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1-Adult patients

Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure.

Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis

BACKGROUND

Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint.

METHODS

A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API).

RESULTS

We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I 2  = 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported.

CONCLUSION

Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.

Veno-arterial extracorporeal membrane oxygenation as cardiogenic shock therapy support in adult patients after heart surgery

Introduction

The authors present their personal experience in qualifying and treating adult patients using veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in postcardiotomy cardiogenic shock.

Aim

The aim of this study was to analyze the results of VA ECMO in patients with postcardiotomy cardiogenic shock. An analysis of the risk factors of postoperative mortality was also performed.

Material and methods

We analyzed the perioperative results of survivors and non-survivors of treatment using VA ECMO. We compared the number of days on VA ECMO therapy, types of cardiac surgical procedures, and the frequency of VA ECMO complications such as coagulation disorders, lower limb ischemia, cardiac tamponade, and renal replacement therapy.

Results

There were 27 patients treated with VA ECMO during the study period. The mean patient age was 45 ±16 years. The hospital mortality rate of patients treated with VA ECMO therapy was 70% (19/27). There were no significant differences between the groups of survivors and non-survivors regarding age, gender, admission type and coexisting diseases. Type of cardiac surgical procedure had no influence on mortality or complications of therapy using VA ECMO.

Conclusions

The VA ECMO can be an effective form of therapy in some patients in postcardiotomy cardiogenic shock.

Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Elderly Patients: Trends in Application and Outcome From the Extracorporeal Life Support Organization (ELSO) Registry

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (RCS) is increasingly used in adult patients, but age represents a controversial factor in this setting.

METHODS

Data from the Extracorporeal Life Support Organization registry was analyzed to assess in-hospital survival of elderly patients (≥70 years of age) undergoing VA-ECMO for RCS from 1992 to 2015. In-hospital survival and complications for elderly patients were compared with data in younger adults (≥18 to <70 years of age) supported with VA-ECMO during the same time period for similar indications.

RESULTS

The mean age of the patient cohort (n = 5,408) was 53.0 ± 15.7 years (range, 18 to 91 years). The elderly group included 735 patients (13.6%), with a mean age of 75.2 ± 4.4 years. In the elderly group, pre-ECMO cardiac procedures were performed in 134 cases (18.9%), and 2.2% received VA-ECMO for postcardiotomy support compared with 0.7% in the younger cohort. The mean duration of VA-ECMO in the elderly group was 101 ± 91 h compared with 138 ± 146 h in the younger group (p < 0.001). Overall, survival to hospital discharge for the entire adult cohort was 41.4% (2,240 of 5,408), with 30.5% (224 of 735) in the elderly patient group and 43.1% (2,016 of 4,673) in the younger patient group (p < 0.001). Elderly patients had a higher rate of multiorgan failure. At multivariable analysis age represented an independent negative predictor of in-hospital survival.

CONCLUSIONS

Based on the acceptable survival to hospital discharge in our study, older age alone should not represent an absolute contraindication when considering VA-ECMO support for RCS.

Levosimendan in patients with left ventricular systolic dysfunction undergoing cardiac surgery on cardiopulmonary bypass: Rationale and study design of the Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial

BACKGROUND

Low cardiac output syndrome is associated with increased mortality and occurs in 3% to 14% of patients undergoing cardiac surgery on cardiopulmonary bypass (CPB). Levosimendan, a novel calcium sensitizer and K_ATP channel activator with inotropic, vasodilatory, and cardioprotective properties, has shown significant promise in reducing the incidence of low cardiac output syndrome and related adverse outcomes in patients undergoing cardiac surgery on CPB.

METHODS

LEVO-CTS is a phase 3 randomized, controlled, multicenter study evaluating the efficacy, safety, and cost-effectiveness of levosimendan in reducing morbidity and mortality in high-risk patients with reduced left ventricular ejection fraction (≤35%) undergoing cardiac surgery on CPB. Patients will be randomly assigned to receive either intravenous levosimendan (0.2 μg kg^-1 min^-1 for the first hour followed by 0.1 μg/kg for 23hours) or matching placebo initiated within 8hours of surgery. The co-primary end points are (1) the composite of death or renal replacement therapy through day 30 or perioperative myocardial infarction, or mechanical assist device use through day 5 (quad end point tested at α<.01), and (2) the composite of death through postoperative day 30 or mechanical assist device use through day 5 (dual end point tested at α<.04). Safety end points include new atrial fibrillation and death through 90days. In addition, an economic analysis will address the cost-effectiveness of levosimendan compared with placebo in high-risk patients undergoing cardiac surgery on CPB. Approximately 880 patients will be enrolled at approximately 60 sites in the United States and Canada between July 2014 and September 2016, with results anticipated in January 2017.

CONCLUSION

LEVO-CTS, a large randomized multicenter clinical trial, will evaluate the efficacy, safety, and cost-effectiveness of levosimendan in reducing adverse outcomes in high-risk patients undergoing cardiac surgery on CPB.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT02025621).

Preoperative Proteinuria and Reduced Glomerular Filtration Rate Predicts Renal Replacement Therapy in Patients Supported With Continuous-Flow Left Ventricular Assist Devices

Background—

Renal failure requiring renal replacement therapy (RRT) has detrimental effects on quality of life and survival of patients with continuous-flow left ventricular assist devices (CF-LVADs). Current guidelines do not offer a decision-making algorithm for CF-LVAD candidates with poor baseline renal function. Objective of this study was to identify risk factors associated with RRT after CF-LVAD implantation.

Methods and Results—

Three hundred and eighty-nine consecutive patients underwent contemporary CF-LVAD implantation at the Columbia University Medical Center between January 2004 and August 2015. Baseline demographics, comorbid conditions, clinical risk scores, and renal function were analyzed in patients with or without RRT after CF-LVAD implantation. Time-dependent receiver-operating characteristic curve analysis was performed to define optimal cutoffs for continuous risk factors. Forty-four patients (11.6%) required RRT during a median follow-up of 9.9 months. Patients requiring RRT had significantly worse renal function, lower hemoglobin, and increased proteinuria at baseline. Low estimated glomerular filtration rate (<40 mL/min/1.73 m 2 ) and proteinuria (urine protein to creatinine ratio ≥0.55 mg/mg) were significant predictors of RRT after CF-LVAD support. Dipstick proteinuria was also a significant predictor of RRT after CF-LVAD implantation. Patients with both low estimated glomerular filtration rate and proteinuria had highest risk of RRT (63.6%) compared with those with either low estimated glomerular filtration rate or proteinuria (18.7%) and those with neither of these risk factors (2.7%) at 1-year follow-up (log-rank P <0.001).

Conclusions—

Estimated glomerular filtration rate and proteinuria are predictors RRT after CF-LVAD implantation and should be routinely assessed in CF-LVAD candidates to guide decision making.

A 20-year multicentre outcome analysis of salvage mechanical circulatory support for refractory cardiogenic shock after cardiac surgery

BACKGROUND

Refractory post-cardiotomy cardiogenic shock (PCCS) is a relatively rare phenomenon that can lead to rapid multi-organ dysfunction syndrome and is almost invariably fatal without advanced mechanical circulatory support (AMCS), namely extra-corporeal membrane oxygenation (ECMO) or ventricular assist devices (VAD). In this multicentre observational study we retrospectively analyzed the outcomes of salvage venoarterial ECMO (VA ECMO) and VAD for refractory PCCS in the 3 adult cardiothoracic surgery centres in Scotland over a 20-year period.

METHODS

The data was obtained through the Edinburgh, Glasgow and Aberdeen cardiac surgery databases. Our inclusion criteria included any adult patient from April 1995 to April 2015 who had received salvage VA ECMO or VAD for PCCS refractory to intra-aortic balloon pump (IABP) and maximal inotropic support following adult cardiac surgery.

RESULTS

A total of 27 patients met the inclusion criteria. Age range was 34-83 years (median 51 years). There was a large male predominance (n = 23, 85 %). Overall 23 patients (85 %) received VA ECMO of which 14 (61 %) had central ECMO and 9 (39 %) had peripheral ECMO. Four patients (15 %) were treated with short-term VAD (BiVAD = 1, RVAD = 1 and LVAD = 2). The most common procedure-related complication was major haemorrhage (n = 10). Renal failure requiring renal replacement therapy (n = 7), fatal stroke (n = 5), septic shock (n = 2), and a pseudo-aneurysm at the femoral artery cannulation site (n = 1) were also observed. Overall survival to hospital discharge was 40.7 %. All survivors were NYHA class I-II at 12 months' follow-up.

CONCLUSION

AMCS for refractory PCCS carries a survival benefit and achieves acceptable functional recovery despite a significant complication rate.

Outcome analysis for prediction of early and long-term survival in patients receiving intra-aortic balloon pumping after cardiac surgery

Background

Patients requiring an intra-aortic balloon pump (IABP) after cardiac surgery are critically ill and need a prolonged ICU stay. Considering limited health care resources, the early identification of patients with an extremely poor prognosis is important as a solid base for the decision whether further aggressive continuation or cessation of the therapy is recommendable.

Methods

From 2001 to 2007, 552 patients with low-output syndrome after open-heart surgery and IABP implantation in OR or within 24 h thereafter on ICU were retrospectively analyzed.

Results

The overall mortality at 30 and 180-day were 31 and 40 %, respectively. According to multivariate analyses, following factors were used to generate an IABP score: female gender, age ≥70 years, simultaneous coronary and valve surgery, aortic cross-clamp time >120 min., need of norepinephrin more than 0.4 µg kg⁻¹ min⁻¹, postoperative dialysis, and maximal serum creatinine kinase >3000 mg mL⁻¹. The 30-day mortality continuously increased along the score (10.1 % for score = 0, n = 98; 11.8 % for score = 1, n = 144; 27.5 % for score = 2, n = 153; 40.4 % score = 3, n = 89; 65.2 % for score = 4, n = 46; 77.8 % for score = 5, n = 27) and reached 100 % for all patients with a score of 6 (n = 4).

Conclusions

Prediction of 30 days mortality was possible with our scoring system based on multivariate analysis, and patients with scores of 4 or greater had remarkably worse early and late survival.

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

Background

Post-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.

Methods

Inclusion 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.

Results

Sixteen 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.

Conclusions

Our 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.

Lessons learned from 150 continuous-flow left ventricular assist devices: a single institutional 7 year experience

Continuous-flow (CF) left ventricular assist devices (LVADs) have become the standard of care for patients with advanced heart failure refractory to optimal medical therapy. The goal of this study was to review our 7 year single institutional experience with CF LVADs. Mean age was 50.4 + 12.5 (17-69) years for bridge-to-transplantation (BTT) patients and 57.6 + 10.4 (31-81) years for destination therapy (DT) patients (p < 0.001). Overall, 38 patients (26%) were female and 58 (41%) were African American. Etiology of heart failure was ischemic in 54 patients (37%) and nonischemic in 93 patients (63%). Overall survival at 30 days, 6 months, 12 months, and 2 years was 93%, 89%, 84%, and 81%, respectively. Gastrointestinal bleeding (GIB) was the most common complication (24%), followed by stroke (18%), right ventricular (RV) failure (18%), ventilator-dependent respiratory failure (10%), reoperation for bleeding (10%), and driveline infection (9%). These data demonstrate excellent survival with low mortality for both BTT and DT patients on long-term LVAD support. However, for LVAD therapy to become the gold standard for long-term treatment of end-stage heart failure and a plausible alternative to heart transplantation, we need to continue to improve the incidence of frequent postoperative complications, such as RV failure, driveline infections, strokes, and GIB.

Clinical Characteristics and Outcomes of Patients With Myocardial Infarction and Cardiogenic Shock Undergoing Coronary Artery Bypass Surgery: Data From The Society of Thoracic Surgeons National Database

BACKGROUND

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with substantial mortality. We evaluated outcomes of patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database who underwent coronary artery bypass graft surgery (CABG) in the setting of AMI-CS.

METHODS

All patients with AMI-CS who underwent nonelective CABG or CABG with ventricular assist device implantation within 7 days after myocardial infarction were enrolled. The primary analysis sample consisted of patients who underwent surgery between June 2011 and December 2013. Baseline characteristics, operative findings, outcomes, and the utilization of mechanical circulatory support (MCS) were assessed in detail in this population. We also evaluated trends in unadjusted mortality for all patients undergoing CABG or CABG with ventricular assist device for AMI-CS from January 2005 to December 2013.

RESULTS

A total of 5,496 patients met study criteria, comprising 1.5% of all patients undergoing CABG during the study period. Overall operative mortality was 18.7%, decreasing from 19.3% in 2005 to 18.1% in 2013 (p < 0.001). Use of MCS increased from 5.8% in 2011 to 8.8% in 2013 (p = 0.008). Patients receiving MCS had a high proportion of cardiovascular risk factors or high clinical acuity. Patients requiring preoperative and patients requiring intraoperative or postoperative MCS had operative mortality of 37.2% and 58.4%, respectively. Patients undergoing CABG as a salvage procedure had an operative mortality of 53.3%, and a high incidence of reoperation (21.8%), postoperative respiratory failure requiring prolonged ventilation (59.7%), and renal failure (18.5%).

CONCLUSIONS

Most patients undergoing CABG for AMI-CS have a sizeable but not prohibitive risk. Patients who require MCS and those undergoing operation as a salvage procedure reflect higher risk populations.

Sex-specific outcomes in patients receiving continuous-flow left ventricular devices as a bridge to transplantation or destination therapy

Reports on sex-related outcomes in left ventricular assist device (LVAD) patients are conflicting. In addition, females have been underrepresented in most multicenter randomized controlled trials for mechanical circulatory support (MCS). The objective of our study was to analyze our experience implanting 130 continuous-flow LVADs and to determine the impact of sex on survival. We identified 130 patients who underwent implantation of a continuous-flow LVAD at our institution. Patients were stratified into two groups based on sex. Variables were compared using two-sided t-tests, χ(2) tests, Cox proportional hazards models, and log-rank tests to determine whether there was a difference between the two groups and if sex was a significant independent predictor of outcome. Of the 130 patients, 35 were females and 95 were males. Female patients had worse pre-LVAD cardiac output and cardiac index and were more likely to be on MCS at the time of implantation. Male patients had worse renal function. Survival was analogous for both cohorts with 30 day, 6 month, 1 year, and 2 year survivals of 97%, 90.8%, 90.8%, and 84.3%, respectively, for female patients versus 94.7%, 87.9%, 78.4%, and 72.8%, respectively, for male patients. The incidence of other LVAD-related complications was also similar in both groups. Gender did not predict postoperative mortality on univariate analysis. Contrary to most published reports, female and male LVAD patients have similar postoperative and midterm survival, length of hospital stay, readmission rates, and postoperative complications. It appears that females have gained more benefit from newer generation devices compared to males.

Pearls and pitfalls in short-term mechanical circulatory assist: how to avoid and manage complications

In today's era, given the worsening risk profiles of patients undergoing cardiac surgery, the increasing number of complex cardiac surgeries, and the increasing number of patients undergoing thoracic organ transplantation, short-term mechanical circulatory assist (MCA) devices are indispensable. MCA devices are capable of supporting heart and lung function and have emerged as potentially lifesaving instruments, but may prove to be as hazardous as helpful due to their inherent tendency toward hemolysis, thromboembolism, and hemorrhage. Although MCA devices are being used regularly at some specialized centers, surgeries involving MCA are not as common as other routine cardiac surgeries, and even though professionals implanting and maintaining short-term MCAs are well acquainted with operating such devices, it is not uncommon to come across complications as a result of minor mistakes committed while dealing with them. Avoiding simple mistakes and taking proper precautions while implanting and maintaining these devices can prevent major catastrophes. We discuss commonly encountered problems and complications during the implantation and maintenance of short-term MCAs and offer reasonable and practical solutions. In addition, crucial issues such as anticoagulation, replacement of the device circuit, and management of the distal perfusion cannula are discussed. Continuous and efficient monitoring of the MCA device and the patient supported on MCA, together with anticipation and avoidance of complications, is key for successful short-term MCA support.

HLA and MICA allosensitization patterns among patients supported by ventricular assist devices

BACKGROUND

Ventricular assist devices (VADs) are increasingly being used as a bridge to transplantation and have been implicated as a risk factor for allosensitization to human leukocyte antigens (HLA). We investigate the association between VAD and allosensitization to human leukocyte antigens (HLA) and major-histocompatibility-complex (MHC) class I-related Chain A (MICA) antigens.

METHODS

We considered all patients who received a VAD at our institution between 2000 and 2009; 89 of them had pre-VAD and post-VAD (≤6 months after implant) HLA antibody screening. A control group of non-VAD heart transplant candidates was constructed with at least 2 pre-transplant panel-reactive antibody (PRA) tests within 8 months. Two controls were randomly selected/VAD patient matched for year (n = 178). Patients and controls with available sera from these time-points were tested by Luminex/flow PRA single-antigen beads and by MICA antibody Luminex single-antigen beads. Medical records were reviewed for comparison of pre-transplant immunologic risk factors and post-transplant outcomes between the 2 groups.

RESULTS

Compared with controls, VAD patients had greater Class I differences between peak and initial PRA (18% vs. 0%, p < 0.0001) and higher peak PRA (24% vs. 6%, p < 0.0001). The differences between the 2 groups in Class II were less pronounced than in Class I. Of patients who had single-antigen testing, VAD implantation was significantly associated with development of new HLA antibody specificities (Class I and/or Class II) post-VAD with an increase in calculated PRA (cPRA) post-VAD compared with controls (16% vs. 0%, p < 0.0001). This risk was still present after adjusting for age, gender, pre-VAD PRA, transfusion and duration of follow-up in a multivariate analysis (p < 0.0001 and 0.02, respectively). There were no differences in development of MICA antibodies between the 2 groups (14% in both). There was no significant difference in the incidence of pre-transplant positive T-cell crossmatch, pre-transplant donor-specific HLA antibodies, rejection episodes or graft survival between the 2 groups.

CONCLUSION

Our results suggest that VAD is associated with significant HLA allosensitization independent of common risk factors.

Mechanical assistance of the circulation during cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock still has a grave prognosis. We present the recent advances in mechanical circulatory support (MCS) for the treatment of refractory cardiogenic shock.

RECENT FINDINGS

The contraindications for short-term MCS in rapid-onset cardiogenic shock are becoming fewer and the threshold for its application has been progressively lowered. Short-term MCS is increasingly used in refractory cardiac arrest and will be probably integrated as the last means in the advanced cardiopulmonary resuscitation algorithm (provided there is experienced team and technical support). Improved device technology has contributed to improved results of long-term MCS. Emergent application of long-term MCS in patients with critical cardiogenic shock after a long history of progressively deteriorating end-stage chronic heart failure should be interpreted as delayed application associated with increased mortality.

SUMMARY

Although MCS can be life saving in cardiogenic shock, the results are still suboptimal. Mortality is associated with the critical presupport state and the adverse events during MCS. Early initiation of support that meets the patient's requirements, potent support in the early phase, adverse event prevention, global combined management (surgical, interventional, medical), balanced support duration, bridging to further therapeutic modalities including heart transplantation or longer-term support, and advanced technology could offer improved results.

Bridging cardiogenic shock patients with short-term ventricular support at a community hospital to long-term ventricular support at a tertiary hospital

BACKGROUND

Patients in cardiogenic shock require immediate circulatory support. Outcomes of patients who underwent short-term ventricular assist device (STVAD) implantation in a community hospital (CH) as a bridge to a long-term VAD (LTVAD) were compared with those who received both implants at the same tertiary hospital (TH).

METHODS

Data were retrospectively reviewed for patients with a STVAD who were bridged to a LTVAD in a TH from 1997 to 2010. We studied outcomes and survival censored for cardiac transplantation.

RESULTS

Thirty-seven patients (73% male) were identified. Mean age was 52 ± 16 years, 30% were diabetic, and 65% had intra-aortic balloon pump support. Reasons for STVAD implantation were an acute myocardial infarction, 38%; post-cardiotomy, 38%, decompensated chronic heart failure, 19%; and others, 5%. A STVAD was implanted in a CH in 20 patients (54%), and they had fewer cardiovascular risk factors than those whose STVAD was implanted at the TH. All patients at the CH were at Interagency Registry for Mechanically Assisted Circulatory Support 1 compared with 71% at the TH (p = 0.014). Patients from the CH tended to die sooner after LTVAD implant, although long-term survival was similar. At the 1-year follow-up, 65% from the CH were alive or had received a transplant vs 60% from the TH.

CONCLUSION

Patients with cardiogenic shock in whom a STVAD was implanted in a CH and then were bridged to a LTVAD in a TH had similar long-term survival as those bridged to LTVAD at the TH.