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Impact of preoperative hemodynamic support on early outcome in patients assisted with paracorporeal Thoratec^® ventricular assist device

^a Service de Chirurgie Thoracique et Cardiovasculaire, Pr. Loisance, AP-HP, Hôpital Henri Mondor, Créteil, France
^b Service de Réanimation Chirurgicale, Pr. Marty, AP-HP, Hôpital Henri Mondor, Créteil, France
^c Service de Réanimation Médicale, Pr. Brun-Buisson, AP-HP, Hôpital Henri Mondor, Créteil, France

Received 8 November 2007; received in revised form 25 March 2008; accepted 27 March 2008.

^_* Corresponding author. Address: 51 Avenue du Maréchal de Lattre de Tassigny, 94 000 Créteil Cédex, France. Tel.: +33 1 49 81 21 72; fax: +33 149 81 21 52. (Email: matthias.kirsch{at}hmn.aphp.fr).

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 5 µg/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 µmol/l and 36.4 ± 53.9 µmol/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.

Key Words: Mechanical circulatory support • Cardiogenic shock • Survival • Adrenaline