title: Continuous-flow left ventricular assist device therapy in patients with preoperative hepatic failure: are we pushing the limits too far?
abstract: The purpose of this study was to evaluate the effects and outcome of continuous-flow left ventricular assist device (cf-LVAD) therapy in patients with preoperative acute hepatic failure. The study design was a retrospective review of prospectively collected data. Included were 42 patients who underwent cf-LVAD implantation (64.3% HeartMate II, 35.7% HeartWare) between July 2007 and May 2013 with preoperative hepatic failure defined as elevation of greater than or equal to two liver function parameters above twice the upper normal range. Mean patient age was 35 ± 12.5 years, comprising 23.8% females. Dilated cardiomyopathy was present in 92.9% of patients (left ventricular ejection fraction 17.3 ± 5.9%). Mean support duration was 511 ± 512 days (range: 2-1996 days). Mean preoperative laboratory parameters for blood urea nitrogen, serum creatinine, total bilirubin, and alanine aminotransferase were 9.5 ± 5.4 mg/dL, 110.3 ± 42.8 μmol/L, 51.7 ± 38.3 mmol/L, and 242.1 ± 268.6 U/L, respectively. All parameters decreased significantly 1 month postoperatively. The mean preoperative modified Model for Endstage Liver Disease excluding international normalized ratio score was 16.03 ± 5.57, which improved significantly after cf-LVAD implantation to 10.62 ± 5.66 (P < 0.001) at 7 days and 5.83 ± 4.98 (P < 0.001) at 30 days postoperatively. One-year and 5-year survival was 75.9 and 48.1%, respectively. 21.4% of the patients underwent LVAD explantation for myocardial recovery, 16.7% were successfully transplanted, and 7.1% underwent LVAD exchange for device failure over the follow-up period. Patients with preexisting acute hepatic failure are reasonable candidates for cf-LVAD implantation, with excellent rates of recovery and survival, suggesting that cf-LVAD therapy should not be denied to patients merely on grounds of "preoperative elevated liver enzymes/hepatopathy."
authors.affiliation: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK; Department of Cardiac Surgery, Heart Center, University of Heidelberg, Heidelberg, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Weymann
authors.forename: Nikhil P
authors.initials: NP
authors.lastname: Patil
authors.forename: Anton
authors.initials: A
authors.lastname: Sabashnikov
authors.forename: Phrashant N
authors.initials: PN
authors.lastname: Mohite
authors.forename: Diana
authors.initials: D
authors.lastname: Garcia Saez
authors.forename: Christian
authors.initials: C
authors.lastname: Bireta
authors.forename: Thorsten
authors.initials: T
authors.lastname: Wahlers
authors.forename: Matthias
authors.initials: M
authors.lastname: Karck
authors.forename: Klaus
authors.initials: K
authors.lastname: Kallenbach
authors.forename: Arjang
authors.initials: A
authors.lastname: Ruhparwar
authors.forename: Javid
authors.initials: J
authors.lastname: Fatullayev
authors.forename: Mohamed
authors.initials: M
authors.lastname: Amrani
authors.forename: Fabio
authors.initials: F
authors.lastname: De Robertis
authors.forename: Toufan
authors.initials: T
authors.lastname: Bahrami
authors.forename: Aron-Frederik
authors.initials: AF
authors.lastname: Popov
authors.forename: Andre R
authors.initials: AR
authors.lastname: Simon
mesh_terms: D000328:Adult; D020878:Device Removal; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D053208:Kaplan-Meier Estimate; D017114:Liver Failure, Acute / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D020127:Recovery of Function; D012189:Retrospective Studies; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016277:Ventricular Function, Left; D055815:Young Adult
keywords: Bridge-to-recovery; Bridge-to-transplantation; Continuous-flow left ventricular assist device; End-organ dysfunction; Hepatic failure