title: Is Implantation of a Left Ventricular Assist Device in Patients With Critical or Impending Cardiogenic Shock an Absolute Contraindication? Looking Back at Our Past Experience Trying to Identify Contraindicative Risk Factors.
abstract: Poor survival has been demonstrated after ventricular assist device (VAD) implantation for Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 and 2 patients compared with more stable levels. However, risk factors within this high-risk cohort have not been determined so far. The aim of the present study was to identify risk factors associated with this very high mortality rate. Between February 1993 and January 2013, 298 patients underwent VAD implantation in our institution. One hundred nine patients were in INTERMACS level 1 and 49 patients were in INTERMACS level 2 and were therefore defined as hemodynamically critical (overall 158 patients). Assist devices implanted were: HVAD HeartWare n = 18; Incor n = 11; VentrAssist n = 2; DeBakey n = 22; and pulsatile systems n = 105. After cumulative support duration of 815.35 months, Kaplan-Meier analysis revealed a survival of 63.9, 48.8, and 40.3% at 1, 6, and 12 months, respectively. Cox regression analyses identified age > 50 (P = 0.001, odds ratio [OR] 2.48), white blood cell count > 13.000/μL (P = 0.01, OR 2.06), preoperative renal replacement therapy (P = 0.001, OR 2.63), and postcardiotomy failure (P < 0.001, OR 2.79) as independent predictors of mortality. Of note, last generation VADs were not associated with significantly better 6-month survival (P = 0.59). Patients without the aforementioned risk factors could yield a survival of 79.2% at 6 months. This single-center experience shows that VAD implantation in hemodynamically unstable patients generally results in poor early outcome, even in third-generation pumps. However, avoiding the aforementioned risk factors could result in improved outcome.
authors.affiliation: Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: Angelo Maria
authors.initials: AM
authors.lastname: Dell'Aquila
authors.affiliation: Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: Stefan R B
authors.initials: SR
authors.lastname: Schneider
authors.affiliation: Epidemiology and Social Psychiatry Unit, Mario Negri Institute for Pharmacological Research, Milan, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Risso
authors.affiliation: Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: Henryk
authors.initials: H
authors.lastname: Welp
authors.affiliation: Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: David G
authors.initials: DG
authors.lastname: Glockner
authors.affiliation: Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Alles
authors.affiliation: Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: Jürgen R
authors.initials: JR
authors.lastname: Sindermann
authors.affiliation: Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: Mirela
authors.initials: M
authors.lastname: Scherer
mesh_terms: D000328:Adult; D000368:Aged; D000075202:Contraindications; D016638:Critical Illness; D005260:Female; D005858:Germany; D006353:Heart-Assist Devices; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D055815:Young Adult
keywords: Extracorporeal membrane oxygenation; Left ventricular assist device; Temporary circulatory support