BIVENTRICULAR SUPPORT IN PATIENTS WITH PROFOUND CAR-DIOGENIC SHOCK

Abstract

Options for managing patients with heart failure who develop cardio-genic shock refractory to inotropic and intra-aortic balloon pump (IABP) therapy are limited. Ventricular assist devices (VADs) may be used in this setting to bridge patients to heart transplantation. However, controversy exists over whether univentricular or biventricular assist devices (Bi-VADs) should be used in this setting, and whether patients should he stabilized with extracorporeal membranous oxygenation prior to VAD placement. Purpose: To report our experience using BiVAD support as a direct bridge to transplantation in heart failure patients with refractory cardiogenic shock. Methods: Review of database. Results: Since July of 1999, we have implanted 19 Thoratec® BiVADs in patients with acute or chronic heart failure unresponsive to maximal medical therapy. Patient ages ranged from 20 to 67 years. Causes of heart failure were: 32% idiopathic, 26% ischemic, 21% post-cardiotomy and 21% other. All patients were in cardiogenic shock, as defined by a cardiac index (Cl)<2.0 L/min/m2and/or a mean arterial pressure of <55 mm Hg. Pre-implant hemodynamics were: mean CI 1.65 L/min/m2(range 0.89–2.36), mean right atrial pressure 19 mm Hg (range 10–30), and mean pulmonary wedge pressure 28 mm Hg (range 17–47). Pre-implant conditions included: IABP 89%, mechanical ventilation 68%, three or more inotropes 84%, acute renal failure (Cr 1.5mg/d/) 63%, hemodialysis 16% and hyperbilirubinemia 59%. Three patients were undergoing CPR immediately prior to BiVAD placement. Results: The duration of BiVAD support averaged 22 days (range 0–91 days). Two patients are currently on support awaiting transplantation. Complications following BiVAD surgery included: bleeding requiring reoperation 26%, cerebral vascular accident 11%, infection (any positive culture) 68% and driveline infection 5%. Excluding the 2 patients who are currently awaiting transplantation, 59% of patients bridged successfully to transplant. Of those transplanted, 90% were discharged from the hospital. Conclusion: In an otherwise moribund patient population, biventricular support with the Thoratec® BiVAD can be used to directly bridge patients successfully to transplantation.