The use of APACHE II scores to select candidates for left ventricular assist device placement. Acute Physiology and Chronic Health Evaluation.
BACKGROUND
The growth in left ventricular assist device (LVAD) use has been hampered by high morbidity and mortality rates and cost. The purpose of this study was to help improve patient selection for LVAD placement by determining whether the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system, a multiparameter, physiology-based predictor of outcome, could be used to predict outcome after LVAD placement and thus help determine optimum timing of LVAD placement.


METHODS
This was a retrospective analysis of a prospective cohort observational study consisting of 2 groups: (1) 50 patients with severe heart failure who did not receive LVAD placement after initial evaluation and (2) 31 patients who did receive LVAD placement. Patients included in the study were in severe heart failure on the basis of 3 of the following: lung crackles, S3, peripheral edema, ejection fraction < 0.30, systolic blood pressure < 80 mm Hg, progressive prerenal azotemia, altered level of consciousness, gastrointestinal ischemia or congestion, or persistent although reversible pulmonary hypertension in spite of maximal medical therapy, including intravenous inotropes. The decision for LVAD placement was at the discretion of the attending physician.


RESULTS
Both LVAD- and non-LVAD-treated patients were similar in cause of heart failure, APACHE II scores, and other baseline laboratory parameters. Survival time with a log-logistic model was better for LVAD-treated patients, p=.0266. Although Kaplan Meier analysis showed a trend toward better survival rates in the LVAD-treated patient, the Cox proportional hazards revealed that LVAD-treated patients had better survival (relative risk ratio, 95% confidence interval=0.305, 0.110 to 0.892; p=.0219) after adjustment for APACHE II score. Each unit increase in APACHE II independently predicted death (relative risk ratios, 95% confidence interval=1.139, 1.055 to 1.231; p=.0009). Patients with medium APACHE II (11 to 20) scores in particular benefitted from LVAD treatment.


CONCLUSIONS
LVAD placement for severe heart failure (not restricted to cardiogenic shock) improves survival. APACHE II can aid in deciding the timing of LVAD placement in patients with heart failure who may not have attained conventional hemodynamic criteria for LVAD placement. Patients who had APACHE II scores between 11 and 20 derived the greatest benefit from LVAD placement.
Gracin
N
N
Section of Critical Care Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Ill 60612, USA.
Johnson
M R
MR
Spokas
D
D
Allen
J
J
Bartlett
L
L
Piccione
W
W
Parrillo
J E
JE
Costanzo
M R
MR
Calvin
J E
JE
D018806:APACHE; D000328:Adult; D000368:Aged; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006353:Heart-Assist Devices; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D015996:Survival Rate; D016896:Treatment Outcome