Bridge to durable left ventricular assist device for refractory cardiogenic shock

Daisuke Yoshioka, Hiroo Takayama, Arthur R Garan, Veli K Topkara, Jiho Han, Boyganzi Li, Paul Kurlansky, Melana Yuzefpolskaya, Paolo C Colombo, Yoshifumi Naka, Koji Takeda
Journal of Thoracic and Cardiovascular Surgery 2017, 153 (4): 752-762.e5

OBJECTIVE: The role of short-term mechanical circulatory support has increased in patients with refractory cardiogenic shock. However, limited data exist on the outcomes of a bridge to a durable left ventricular assist device strategy using short-term mechanical circulatory support.

METHODS: We retrospectively reviewed 382 patients who underwent continuous-flow left ventricular assist device insertion between 2004 and 2014. Of these, 45 (12%) were bridged with short-term mechanical circulatory support devices for refractory cardiogenic shock. We analyzed early and midterm outcomes in this bridged cohort. Multivariate Cox proportional hazards modeling was performed to evaluate the predictor of overall death in the entire cohort.

RESULTS: The mean age of the bridged cohort was 53 ± 10 years, and 87% were male. The types of initial support included percutaneous devices in 24 patients (53%) and external continuous-flow ventricular assist device in 21 patients (47%). The median duration of short-term mechanical circulatory support was 14.0 (interquartile range, 7.5-29.5) days. The short-term mechanical circulatory support significantly improved end-organ function and hemodynamics. After conversion to durable left ventricular assist device insertion, in-hospital mortality was 18%. The incidence of right ventricular assist device use was high at 27%. The overall survival was 70% and 62% at 1 and 2 years, respectively. Cox multivariate hazard analysis in the entire cohort demonstrated that the use of a postoperative right ventricular assist device was a significant predictor of overall death (hazard ratio, 4.04; P < .001; 95% confidence interval, 1.97-7.94), but the use of a short-term mechanical circulatory support was not (P = .937).

CONCLUSIONS: Short-term mechanical circulatory support can optimize patients in refractory cardiogenic shock and serve as a bridge to implantation of a durable left ventricular assist device. However, the early mortality rate after durable left ventricular assist device implantation is high because of unrecognized right ventricular failure.

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