Extracorporeal life support prior to left ventricular assist device implantation leads to improvement of the patients INTERMACS levels and outcome

Schibilsky, David; Haller, Christoph; Lange, Bruno; Schibilsky, Barbara; Haeberle, Helene A.; Seizer, Peter; Gawaz, Meinrad; Rosenberger, Peter; Walker, Tobias; Schlensak, Christian

doi:10.1371/journal.pone.0174262

Cited by 26 publications

(19 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We considered patients weanable from pVA‐ECMO without transition to dMCS if they met the following criteria during a weaning trial, that is, clamped ECMO circuit for 1 min: cardiac index ≥2.4, central venous pressure ≤18 mm Hg, PCWP ≤18 mm Hg, and a LV ejection fraction >30% with minimal inotropic support (≤0.02 µg/kg/min epinephrine or equivalent). Available studies describing implantation of dMCS following short‐term mechanical circulatory support for cCS, including pVA‐ECMO, showed preimplant hemodynamic data in good agreement with our weaning criteria …”

Section: Methodssupporting

confidence: 82%

See 1 more Smart Citation

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

et al. 2019

View full text Add to dashboard Cite

Peripheral veno‐arterial extracorporeal membrane oxygenation (pVA‐ECMO) has gained increasing value in the management of patients with critical cardiogenic shock (cCS), allowing time for myocardial recovery. Failure of myocardial recovery has life‐altering consequences: transition to durable mechanical circulatory support (dMCS), urgent heart transplantation, or withdrawal of support. Clinical factors controlling myocardial recovery under these circumstances remain largely unknown. Using a retrospective cohort, we developed a model for early prediction of transition to dMCS in patients undergoing pVA‐ECMO for cCS. To promote myocardial recovery, our clinical management centered around left ventricular pressure unloading, that is, targeting pulmonary capillary wedge pressures (PCWP) ≤18 mm Hg. We collected demographic data, laboratory findings, inotrope use, and two‐dimensional transthoracic echocardiography measurements, all limited to the first 72h of pVA‐ECMO (D1‐3). Out of 70 patients who were alive after pVA‐ECMO, 27 patients underwent implantation of dMCS. There was no significant difference in survival to hospital discharge between patients with or without transition to dMCS. Ejection fractionD1‐3 (per 10% increase, OR 0.37 [0.17‐0.79]) and amount of inotropic supportD1‐3 (OR 4.77 [1.6‐14.18]) but neither myocardial wall tension nor PCWP emerged as significant predictors of transition to dMCS. Optimism‐corrected c‐index (0.90 [0.89‐0.90]) revealed an excellent discriminative ability of our model. In summary, our model for early prediction of transition to dMCS in patients with cCS undergoing pVA‐ECMO identifies indicators of inotropic state as relevant factors. Absence of markers for myocardial oxygen consumption or left ventricular pressure loading allows us to hypothesize sufficient cardiac unloading in our cohort with PCWP‐targeted management.

show abstract

Section: Methodssupporting

confidence: 82%

“…Available studies describing implantation of dMCS following short-term mechanical circulatory support for cCS, including pVA-ECMO, showed preimplant hemodynamic data in good agreement with our weaning criteria. [14][15][16]…”

Section: Clinical Managementmentioning

confidence: 99%

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

et al. 2019

View full text Add to dashboard Cite

show abstract

“…Accordingly, a bridge-to-bridge strategy has been implemented as a salvage option for selected high-risk patients, in an attempt to stabilize end-organ function and improve outcomes, as it was recently shown. [17][18][19] As expected, the duration of ICU and hospital stay exceeded those of patients with uncomplicated weaning. Tracheostomy was performed in 63% of patients on PMV, according to existing evidence for improved outcomes.…”

Section: Discussionsupporting

confidence: 75%

“…A significant proportion of patients were on critical or rapidly declining clinical state (overall 59% in INTERMACS Level 1-3) and non-eligible for bridging therapies. [17][18][19] As expected, the duration of ICU and hospital stay exceeded those of patients with uncomplicated weaning. 12,13 Destination therapy is repeatedly shown to be an independent predictor of death, and this may have led to an increase in the reported PMV rates and mortality.…”

Section: Prolonged Ventilation After Lvadsupporting

confidence: 75%

Prolonged mechanical ventilation after left ventricular assist device implantation: risk factors and clinical implications

et al. 2019

View full text Add to dashboard Cite

Aims Unsuccessful weaning from ventilator after major cardiovascular procedures has been shown to be associated with increased post‐operative morbidity and mortality. Our study aimed to identify predictors and clinical implications of prolonged mechanical ventilation (PMV) after left ventricular assist device (LVAD) implantation. Methods and results We analysed the data of patients receiving a continuous‐flow LVAD in our centre from December 2010 to September 2017. PMV was defined by a duration of invasive ventilation of >7 days after LVAD implantation. Multivariable logistic regression analysis was performed for predictors of PMV. Survival was estimated by the Kaplan–Meier method. During the study period, 156 patients received a continuous‐flow LVAD in our centre. Seventeen patients were excluded due to early death (<7 days), and 139 patients were enrolled in the study (mean age: 58 years; male: 84%). The median duration of mechanical ventilation post‐operatively was 94 h (range: 5 to 4192 h). PMV was observed in 43% of patients. Patients on PMV were characterized by a more severe disease state at baseline, compared with the group of early extubation, as reflected by their Interagency Registry for Mechanically Assisted Circulatory Support level (Level 1–3: 72 vs. 49%, P = 0.008). Patients on PMV exhibited higher pulmonary wedge pressures (25 vs. 21 mmHg, P = 0.04), lower estimated glomerular filtration rate (53 vs. 60 mL/min/1.73 m 2 , P = 0.02), lower haemoglobin (10.6 vs. 11.6 g/dL, P = 0.02), and lower platelet counts (189 vs. 240/nL, P = 0.02). Previous sternotomy was more frequent in the PMV group (32 vs. 13%, P = 0.006). Higher rates of preoperative circulatory support (30 vs. 11.4%, P = 0.006), dialysis (31.7 vs. 10.1%, P = 0.001), and invasive ventilation (35 vs. 7.6%, P < 0.001) were reported for the PMV group. Logistic regression analysis revealed that estimated glomerular filtration rate [odds ratio (OR) 0.977, confidence interval (CI) 0.955–0.999, P = 0.038], platelet count (OR 0.994, CI 0.989–0.998, P = 0.008), and previous sternotomy (OR 5.079, CI 1.672–15.427, P = 0.004) were independent predictors of PMV. PMV was accompanied by longer intensive care unit (24 vs. 4 days, P < 0.001) and hospital stay (47 vs. 32 days, P = 0.003). Survival analysis revealed a profound increase in mortality at 180‐day post‐implantation in the PMV group (62 vs. 10%, log‐rank: P < 0.001). Conclusions Prolonged mechanical ventilation affects nearly half of patients after LVAD implantation. Previous ste...

show abstract

“…The 1‐year survival rate (86.4%) was better than INTERMACS 1 in refractory cardiogenic shock without preimplantation ECLS (74%) . Schibilsky et al also demonstrated similar results. Thus, ECLS enables the stabilization and normalization of end‐stage organ failure (respiratory, renal, and liver) before LVAD implantation.…”

Section: Discussionmentioning

confidence: 83%

Independent risk factors for ICU mortality after left ventricular assist device implantation

Piffard

Coniat²,

Simon

et al. 2019

Artificial Organs

View full text Add to dashboard Cite

Funding informationOnly departmental funds were used for this study. AbstractLeft ventricular assist devices (LVADs) are used as an alternative therapy for heart transplantation in patients with advanced heart failure. However, the mortality rate of these patients remains relatively high. A large proportion of deaths after LVAD implantation occur during intensive care unit (ICU) stay. We conducted a retrospective study to identify the risk factors for all-cause ICU mortality in patients with an implanted LVAD. Between January 1, 2008 and December 31, 2016, 70 consecutive patients who had received an LVAD were analyzed. The median ICU length of stay was 14 days (IQR: 8-31) and 16 patients (22.9% [95%CI: 13.1-32.7]) died in the ICU. The 90-day mortality rate was 25.7% (95%CI: 15.5-35.9). The main causes of ICU mortality were: multiple organ failure, stroke, and hemorrhagic events. The univariate analysis identified the following perioperative risk factors for all-cause ICU mortality: hypertension, preoperative platelet count, preoperative white cell count, inotropic support before LVAD implantation, mechanical ventilation before LVAD implantation, renal replacement therapy before LVAD implantation, shortterm mechanical support before LVAD implantation, INTERMACS class 1 to 2, low intraoperative platelet count, low early postoperative hemoglobin level, low early postoperative platelet count, low early postoperative pH, and massive perioperative blood transfusion. In the multivariate logistic regression analysis, only mechanical ventilation before LVAD implantation was retained as an independent risk factor for ICU mortality (OR = 11.96 [95%CI: 2.67-53.45], P < .01). These findings confirm that most deaths after LVAD implantation occur in the ICU. Patients that receive mechanical ventilation preoperatively have the highest risk of death. This confirms the need to actively treat respiratory failure and to wean patients from respiratory support before LVAD implantation. Such a strategy offers the best opportunity to initiate active rehabilitation. K E Y W O R D S Intensive care unit, left ventricular assist device, mortality, outcome, predictive factors, respiratory assistance 154 | PIFFARD et Al How to cite this article: Piffard M, Nubret-Le Coniat K, Simon O, et al. Independent risk factors for ICU mortality after left ventricular assist device implantation.

show abstract

Extracorporeal life support prior to left ventricular assist device implantation leads to improvement of the patients INTERMACS levels and outcome

Cited by 26 publications

References 16 publications

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

Prolonged mechanical ventilation after left ventricular assist device implantation: risk factors and clinical implications

Independent risk factors for ICU mortality after left ventricular assist device implantation

Contact Info

Product

Resources

About