Impact of preoperative hemodynamic support on early outcome in patients assisted with paracorporeal Thoratec ventricular assist device.
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.
Kirsch
Matthias
M
Service de Chirurgie Thoracique et Cardiovasculaire, Pr. Loisance, AP-HP, Hôpital Henri Mondor, Créteil, France. matthias.kirsch@hmn.aphp.fr
Vermes
Emmanuelle
E
Radu
Costin
C
Streich
Birgit
B
Nakashima
Kuniki
K
Mekontso-Dessap
Armand
A
Loisance
Daniel
D
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
D014662:Vasoconstrictor Agents; D004837:Epinephrine