BackgroundThe 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.Methods & resultsAll 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.ConclusionLVAD 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 catheter-based Impella 5.0 left ventricular assist device is a powerful and less invasive alternative for patients in cardiogenic shock. The use as second-line therapy in patients with precedent extracorporeal life support (ECLS) has not been described before now. We analyzed our experience of consecutive patients treated with this alternative strategy. From April 2014 to December 2014, eight patients had been implanted as a second-line option after ECLS support. The reason for the change from ECLS to Impella 5.0 was absence of cardiac recovery for primary weaning and complications of ECLS therapy. The mean time of ECLS support prior to Impella implantation was 12 ± 7 days. The implantation of the Impella 5.0/CP was technically successful in all patients, and the ECLS could be explanted in all eight patients who received Impella implantation as a second-line treatment. The second-line Impella 5.0 therapy resulted in two patients who turned into left ventricular assist device (LVAD) candidates, two primary weaning candidates, and four patients who died in the setting of sepsis or absent cardiac recovery and contraindications for durable LVAD therapy. Thereby, the overall hospital discharge survival as well as the 180-day survival was 50% for Impella 5.0 implantations as second-line procedure after ECLS. The latest follow-up survival of this second-line strategy after ECLS was three out of eight, as one patient died after 299 days of LVAD support due to sepsis. The use of Impella 5.0 constitutes a possible second-line therapeutic option for those patients who do not show cardiac recovery during prolonged ECLS support or suffer from complications of ECLS therapy. This treatment allows additional time for decisions regarding cardiac recovery or indication for durable LVAD therapy.

The specific hemocompatibility properties of mechanical-circulatory-support (MCS)-pump technologies have not previously been described in a comparable manner. We thus investigated the hemocompatibility-indicating marker of a new magnetically-levitated (MagLev) centrifugal pump (MT-Mag) in a human, whole-blood mock-loop for 360 min using the MCS devices as a driving component. We compared those results with the CentriMag adult (C-Mag) device under the same conditions according to ISO10993-4. Blood samples were analyzed via enzyme-linked-immunosorbent-assay (ELISA) for markers of coagulation, complement system, and the inflammatory response. The time-dependent activation of the coagulation system was measured by detecting thrombin-anti-thrombin complexes (TAT). The activation of the complement system was determined by increased SC5b-9 levels in both groups. A significant activation of neutrophils (PMN-elastase) was detected within the C-Mag group, but not in the MT-Mag group. However, the amount of PMN-elastase at 360 min did not differ significantly between groups. The activation of the complement and coagulation system was found to be significantly time-dependent in both devices. However, coagulation activation as determined by the TAT level was lower in the MT-Mag group than in the C-Mag group. This slight disparity could have been achieved by the optimized secondary flow paths and surface coating, which reduces the interaction of the surface with blood.