title: Impact of preoperative hemodynamic support on early outcome in patients assisted with paracorporeal Thoratec ventricular assist device.
abstract: BACKGROUND
  Mechanical circulatory support has become a well-established procedure for some patients with cardiogenic shock. However, patient selection and timing of implantation remains critical. This retrospective study was undertaken to identify preoperative predictors of survival in ICU of patients requiring mechanical circulatory support.
  
  
  METHODS
  Between 1996 and 2006, 71 patients (61 men, 10 women, aged 41.6+/-12.2 years) with primary cardiogenic shock were assisted using the paracorporeal Thoratec VAD. Twenty-seven (38%) patients needed preoperative mechanical ventilation. Preoperative IV hemodynamic drug support included dobutamine in 63 (89%), vasopressors (adrenaline, noradrenaline or dopamine > or =5 microg/kg min) in 47 (66%), and intraaortic balloon counter-pulsation in 22 (31%) patients. Mean preoperative blood creatinine and total bilirubin levels were 162.2+/-72.4 micromol/l and 36.4+/-53.9 micromol/l, respectively.
  
  
  RESULTS
  Fifty-six (79%) patients required biventricular and 15 (21%) left ventricular support. Patients were assisted for a mean duration of 73.1+/-93.6 days (extremes, 1-480 days). Twenty-five patients (35%) died while on support. Among these, 18 patients (25%) never recovered sufficiently to allow dismissal from ICU, and died after a mean of 15.4+/-14.3 days. Logistic regression identified preoperative IV adrenaline as sole predictor for ICU death (OR, 5.48; 95% CI, 1.45-20.7, p=0.012).
  
  
  CONCLUSIONS
  The need for preoperative IV adrenaline therapy appeared to be the sole independent risk factor for death in ICU in patients assisted with the Thoratec paracorporeal VAD. This suggests that, besides hemodynamic and metabolic consequences of cardiogenic shock, preoperative activation of the inflammatory cascade could influence the prognosis of patients undergoing mechanical circulatory support.
authors.affiliation: Service de Chirurgie Thoracique et Cardiovasculaire, Pr. Loisance, AP-HP, Hôpital Henri Mondor, Créteil, France. matthias.kirsch@hmn.aphp.fr
authors.forename: Matthias
authors.initials: M
authors.lastname: Kirsch
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Vermes
authors.forename: Costin
authors.initials: C
authors.lastname: Radu
authors.forename: Birgit
authors.initials: B
authors.lastname: Streich
authors.forename: Kuniki
authors.initials: K
authors.lastname: Nakashima
authors.forename: Armand
authors.initials: A
authors.lastname: Mekontso-Dessap
authors.forename: Daniel
authors.initials: D
authors.lastname: Loisance
mesh_terms: D000293:Adolescent; D000328:Adult; D001243:Assisted Circulation; D004812:Epidemiologic Methods; D004837:Epinephrine / Q000008:administration & dosage / Q000009:adverse effects; D005260:Female; D006353:Heart-Assist Devices; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods*; D011379:Prognosis; D012770:Shock, Cardiogenic / Q000188:drug therapy / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D014662:Vasoconstrictor Agents; D004837:Epinephrine