Importance of preoperative liver function as a predictor of survival in patients supported with Thoratec ventricular assist devices as a bridge to transplantation.
Patient selection is crucial for the success of ventricular assist devices as a bridge to heart transplantation.


OBJECTIVE
The objective of this study was to identify preoperative markers for survival and end-organ recovery in patients having a ventricular assist device.


METHODS
A retrospective study was performed on 32 severely ill patients with end-stage cardiac failure being mechanically bridged to heart transplantation with the Thoratec Ventricular Assist Device System (Thoratec Laboratories Corporation, Pleasanton, Calif) in a single center between 1984 and 1995. The preoperative cardiac index averaged 1.6 L/min per square meter with a pulmonary capillary wedge pressure of 29 mm Hg. Because of a high incidence of hepatic or renal dysfunction, or both (total bilirubin: 3.5 +/- 6.2 mg/dL; creatinine: 2.0 +/- 1.3 mg/dL), biventricular support was used in most patients (28/32). A total of 30 preoperative and 4 perioperative variables were evaluated for their association with survival and liver recovery.


RESULTS
Nineteen patients (59.4%) survived to transplantation and 13 died. All 19 patients undergoing transplantation were discharged alive with a 1-year survival of 94.4%. All patients without liver recovery died of multiorgan failure. Direct and indirect bilirubin measurements were the only significant predictors for survival to discharge (P = .036, .045); all other factors failed to show significance. As direct bilirubin levels increased (normal range, 3 times normal, and >3 times normal), patient survival decreased (82 %, 56%, and 33 %, respectively). In addition, bilirubin and liver enzyme levels before insertion of the assist device were significantly associated with liver recovery during support with the device.


CONCLUSIONS
In our patient population with ventricular assist devices, liver function is the most predictive factor of patient survival in bridging to transplantation.
Department of Cardiac Surgery, California Pacific Medical Center, San Francisco 94115, USA.
O
O
Reinhartz
D J
DJ
Farrar
J H
JH
Hershon
G J
GJ
Avery
E A
EA
Haeusslein
J D
JD
Hill
D000328:Adult; D002423:Cause of Death; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality* / Q000601:surgery; D016027:Heart Transplantation / Q000401:mortality; D006353:Heart-Assist Devices; D006801:Humans; D017093:Liver Failure / Q000401:mortality; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000401:mortality; D011237:Predictive Value of Tests; D051437:Renal Insufficiency / Q000401:mortality; D012189:Retrospective Studies; D015996:Survival Rate