Date Published: March 30, 2017
Publisher: Public Library of Science
Author(s): David Schibilsky, Christoph Haller, Bruno Lange, Barbara Schibilsky, Helene Haeberle, Peter Seizer, Meinrad Gawaz, Peter Rosenberger, Tobias Walker, Christian Schlensak, Andreas Schäfer.
The objective of this study was to evaluate the outcome of left ventricular assist device (LVAD) implantation after initial extracorporeal life support (ECLS) in patients with cardiogenic shock and the incidence of post implantation right ventricular failure.
All patients on ECLS therapy for cardiogenic shock prior to LVAD implantation (n = 15) between October 2011 and January 2014 were analyzed. Baseline patient characteristics, as well as detailed pre-operative treatment and postoperative outcome data were collected retrospectively. At time of admission to our unit all patients were classified INTERMACS II or higher (12 [80%] INTERMACS I). Improvement to INTERMACS III temporary cardiac support (TCS) at time of LVAD implantation was successful in 14 patients (93.3%). End-organ function recovered during ECLS support. No patient needed ongoing ECLS or additional right ventricular support after LVAD implantation. Both in-hospital and 30-day mortality was 6.7% (n = 1). The median duration of LVAD support was 687.9 ± 374.5 days. At the end of the study (follow-up 810.7 +/- 338.9 days), 13 (86.7%) patients were alive. The majority of patients (10 [66.7%]) remained on LVAD support. Transplantation could be performed in 1 (6.7%) patient, 2 (13.3%) patients could be successfully weaned.
LVAD implantation in ECLS patients leads to improvement of INTERMACS level to INTERMACS III TCS status. Excellent mid-term survival comparable to true INTERMACS III-IV patients could be shown. ECLS prior to LVAD as a bridge-to-bridge therapy may help to lower mortality in primarily unstable patients.
The growing expertise of specialized ventricular assist device (VAD) centers led to significant improvement in survival rates in current years. However, mortality remains high, especially in INTERMACS I and II patients. The number of patients who are considered too sick for VAD support and their outcome is unknown. Therefore LVAD implantation should be performed prior to the development of cardiogenic shock. Nevertheless, the best treatment for patients presenting in INTERMACS I or II is still a matter of debate.
We analyzed all LVAD patients undergoing ECLS treatment and subsequent continuous flow LVAD implantation at our center between October 2011 and January 2014 (n = 15).
At time of admission to our unit or at time of ECLS implantation at the referring hospital 13 out of 15 (86.7%) patients met INTERMACS level I and 3 met INTERMACS level II criteria (Table 1). The use of ECLS stabilized 14 (93.3%) of these patients achieving INTERMACS III TCS (temporary cardiac support) prior to LVAD implantation.
Our study demonstrates a favorable outcome of LVAD implantation in patients bridged on ECLS. Furthermore, no right heart failure occurred after LVAD implantation.
The use of ECLS prior to LVAD implantation results in excellent survival and avoidance of biventricular support in cardiogenic shock patients (INTERMACS I and II). Survival rates are comparable to those seen in patients in INTERMACS III to IV. Therefore, we conclude that patients benefit from initial stabilization to INTERMACS III TCS on ECLS prior to LVAD implantation.