title: Preoperative patient optimization using extracorporeal life support improves outcomes of INTERMACS Level I patients receiving a permanent ventricular assist device.
abstract: OBJECTIVE
  Interagency Registry for Mechanical Assisted Circulatory Support (INTERMACS) Level I patients have the highest early mortality after ventricular assist device (VAD) implantation. This is determined by the exposure of patients in shock with acutely damaged end-organs and high catecholamine support to a significant surgical trauma. We report our experience with a bridge-to-bridge concept consisting of initial veno-arterial extracorporeal life support (ECLS) and deferral of VAD implantation to recovery of end-organ function in INTERMACS Level I patients.
  
  
  METHODS
  We reviewed the concept of initial ECLS implantation and deferral of VAD implantation to end-organ recovery in 22 consecutive patients (mean age 54 ± 14 years; 72.2% males; 50% ischemic cardiomyopathy; 100% INTERMACS Level I; 18.2% Heartmate II, 68.2% Heartware HVAD, 4.5% Heartware BiVAD, 9.1% DeBakey LVAD) receiving a VAD for refractory cardiogenic shock between June 2004 and February 2013. Study endpoints were end-organ recovery during ECLS and survival.
  
  
  RESULTS
  ECLS significantly improved renal (creatinine 1.86 ± 0.91 vs 1.32 ± 0.52 mg/dl, P = 0.02), hepatic (aspartate aminotransferase 1426 ± 2176 vs 277 ± 259 U/l, P = 0.04; alanine aminotransferase 982 ± 1466 vs 357 ± 447 U/l, P = 0.04) and pulmonary functions (fraction of inspired oxygen 52 ± 18 vs 26 ± 23%, P < 0.01; positive end-expiratory pressure 7 ± 3 vs 5 ± 4 mbar, P = 0.02) over a period of 8 ± 7 days. Catecholamines could be reduced during ECLS (levosimendan 0.056 ± 0.085 vs 0.010 ± 0.032 μg/kg/min, P = 0.06; dobutamine 4.362 ± 5.268 vs 0.056 ± 0.097 μg/kg/min, P = 0.06; noradrenaline 0.408 ± 0.355 vs 0.056 ± 0.097 μg/kg/min, P < 0.01). Thirty-day and in-hospital mortality after VAD implantation were 4.5 and 9.1%, respectively, and 1-year survival was 86.4%.
  
  
  CONCLUSIONS
  Preoperative patient optimization using ECLS improves outcomes of INTERMACS Level I patients receiving a permanent VAD.
authors.affiliation: Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria.
authors.forename: Julia
authors.initials: J
authors.lastname: Riebandt
authors.affiliation: Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Haberl
authors.affiliation: Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria.
authors.forename: Stephane
authors.initials: S
authors.lastname: Mahr
authors.affiliation: Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria.
authors.forename: Guenther
authors.initials: G
authors.lastname: Laufer
authors.affiliation: Department of Anesthesia, General Intensive Care and Pain Management, Medical University Vienna, Vienna, Austria.
authors.forename: Angela
authors.initials: A
authors.lastname: Rajek
authors.affiliation: Department of Anesthesia, General Intensive Care and Pain Management, Medical University Vienna, Vienna, Austria.
authors.forename: Barbara
authors.initials: B
authors.lastname: Steinlechner
authors.affiliation: Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria.
authors.forename: Heinrich
authors.initials: H
authors.lastname: Schima
authors.affiliation: Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria daniel.zimpfer@meduniwien.ac.at.
authors.forename: Daniel
authors.initials: D
authors.lastname: Zimpfer
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000379:methods*; D005112:Extracorporeal Circulation / Q000379:methods*; D005260:Female; D006353:Heart-Assist Devices; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Extracorporeal life support; INTERMACS Level; Ventricular assist device