Prediction of Survival in Patients With Cardiogenic Shock and Multiorgan Failure Treated With Biventricular Assist Device

Abstract

Mechanical circulatory support (MCS) is valuable in saving the lives of patients with severe cardiogenic shock. However, their survival is limited if multiorgan failure (MOF) proves to be irreversible. Although ventricular assist devices (VADs) have been shown to reverse end-organ failure in some patients, the pathophysiological mechanisms of end-organ failure and its regression are not fully understood, and clinical markers and thresholds for the "point of no return" are lacking. We investigated predictors of 30-day survival in patients supported with a biventricular assist device (BVAD). We studied 157 patients implanted with a Berlin Heart EXCOR BVAD between 1987 and 2006. Children younger than 10 years and cases with postcardiotomy syndrome and transplant failure were excluded from the analysis as well as patients with technical or bleeding problems requiring rethoracotomy. In total, 69 clinical, hemodynamic, echocardiographic, and laboratory parameters were evaluated. Most of the patients suffered from ischemic cardiomyopathy or acute myocardial infarction. In addition, the preoperative multiple organ dysfunction syndrome (MODS) and the sequential organ failure assessment (SOFA) scores were calculated. The patients were divided into two groups regarding procedural success: group I-survival >30 days or heart transplantation or weaning from device (n = 105) and group II-death on system <30 days after surgery (n = 52). The 30-day procedural success rate was 67%. The patients in group I had higher systolic blood pressure (96.7 vs. 90.1 mm Hg, p = 0.027), lower serum creatinine (1.96 vs. 2.4 mg/dl, p = 0.001), and higher arterial pH (7.43 vs. 7.37, p = 0.02). The multivariate analysis recognized age, body temperature, systolic blood pressure, MODS score, and higher arterial pH as significant predictors for 30-day mortality. Standard markers for severity of cardiogenic shock and MOF do not predict survival on BVAD. As expected, older patients are at higher risk for death on BVAD. Acidosis and high MODS score predict unfavorable outcome. However, the prediction of clinical outcome in patients in severe cardiogenic shock supported by BVAD is possible in extreme situations only.

Thoratec paracorporeal biventricular assist device therapy: the Freiburg experience

“…Despite the disease's different etiologies, factors such as older age are known risk factors of dying on BVAD support [17]. This fact could be affirmed by our study as group 1 patients were younger than group 2 patients.…”

Advances in mechanical circulatory support: Year in review

“…Earlier implementation of advanced circulatory support (e.g., by VAD) may improve the outcome in patients with post-cardiotomy cardiogenic shock. [7][8][9] In some cases, a combination of the two devices, the TandemHeart for right and the Impella for short-term left ventricular support, may be helpful. 10 The recent introduction of the Levitronix pump (Levitronix, Waltham, MA), employing magnetic levitation for short-term support, 11 did not solve the problems of patient selection, severe multi-organ failure or need for thoracotomy in some cases, but advanced technology with a low level of hemolysis allows the pump to run for several weeks and the support to be weaned at low speed.…”

“…In recent years many scores have been developed to predict outcome after VAD implantation. 7,9,20,21 Klotz et al found that easily obtained and quickly accessible clinical parameters can inform potential patients, relatives and physicians pre-operatively about the risk of death in the intensive care unit (ICU) after VAD implantation. 9 Similar to previous studies, the Seattle Heart Failure Model allows prediction of the major features of a patient's course post-operatively, including length of hospital stay and 1-year survival.…”

“…The only meaningful conclusion is that, based on evidence of improved survival and shorter hospital stay in lower risk patients, earlier VAD placement based on a prediction model should be considered in advanced heart failure patients. 7,20 One of the selection criteria is patient age, with a focus on the benefit of permanent MCS in elderly patients. 22 At our institution, the oldest woman successfully supported for several years with the Jarvik 2000 was 80 years of age and the oldest man was 82 years of age, supported with a HeartWare LVAD.…”

Percutaneous Circulatory Support for Biventricular Failure

“…1 AST indicates aspartate aminotransferase; BP, blood pressure; CI, cardiac index; CVP, central venous pressure; IABP, intra-aortic balloon pump; PAP, pulmonary artery pressure; PAPI, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; RA, right atrial; RVAD, right ventricular assist device; and SVR, systemic vascular resistance.…”