Implantable left ventricular assist devices as initial therapy for refractory postmyocardial infarction cardiogenic shock.

OBJECTIVES Recently, the initial therapy for refractory cardiogenic shock has largely been based on use of short-term mechanical devices with later conversion to durable options. The premise is that such patients cannot tolerate cardiopulmonary bypass and the extended surgery needed for implantable left ventricular assist device (LVAD) placement. We have adopted an alternative strategy to implant long-term LVADs as the initial device therapy in such patients. METHODS Over a 3 year period, we used implantable LVADs (Jarvik 2000, one; Ventrassist, one; Heartmate XVE, two; and Heartmate II, nine) in 13 patients (11 men and two women; mean age 54 years) with postmyocardial infarction shock without prior use of a short-term LVAD. The median time interval from myocardial infarction to LVAD implantation was 3.5 days. Eight patients were on a ventilator, two had unknown neurological status and four had suffered cardiac arrest in the preceding 24 h. Two had prior coronary artery bypass graft. Nine had received dual antiplatelet therapy postmyocardial infarction. The mean laboratory value of creatinine was 1.5 mg/dl, alanine aminotransferase 748 U/l, international normalized ratio 1.5 and lactate 3.2 mmol/l. One procedure was carried out off pump; for the others, the mean cardiopulmonary bypass time was 72 min. Right ventricular assist devices were used in two cases and were later explanted. RESULTS One patient died of progressive multiorgan failure. All others survived to hospital discharge. There were no re-explorations for bleeding or major infectious complications; two patients had perioperative stroke. The median duration of mechanical ventilation, intensive care unit stay and hospital stay was 3, 9 and 18 days, respectively. At 1 year, of the 12 survivors, eight have since had heart transplant, one patient underwent device explant, two remained alive on support and one died 7 months post-LVAD. CONCLUSIONS Our data challenge the notion that patients in refractory cardiogenic shock are too ill to tolerate immediate placement of implantable LVADs. Despite the surgical challenges, a one-stop implantable LVAD approach for cardiogenic shock is feasible and may offer unique advantages over the bridge-to-bridge approach because it avoids the incremental costs, hospitalization and morbidity associated with repeated interventions.

[1]  Douglas L. Mann,et al.  Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th edition , 2018 .

[2]  P. Loyalka,et al.  Current status of percutaneous ventricular assist devices for cardiogenic shock , 2011, Current opinion in cardiology.

[3]  A. Anyanwu Technique for less invasive implantation of Heartmate II left ventricular assist device without median sternotomy. , 2011, Seminars in thoracic and cardiovascular surgery.

[4]  M. Hoeper,et al.  Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. , 2011, The Annals of thoracic surgery.

[5]  James W Long,et al.  Outcomes of a multicenter trial of the Levitronix CentriMag ventricular assist system for short-term circulatory support. , 2011, The Journal of thoracic and cardiovascular surgery.

[6]  Douglas P. Zipes,et al.  Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 2-Volume Set, 10th Edition , 2011 .

[7]  C. O'connor,et al.  Long-term outcomes and costs of ventricular assist devices among Medicare beneficiaries. , 2008, JAMA.

[8]  K. Chatterjee,et al.  Analytic Reviews: Cardiogenic Shock with Preserved Systolic Function: A Reminder , 2008, Journal of intensive care medicine.

[9]  M. Slaughter,et al.  Acute myocardial infarction complicated by cardiogenic shock: role of mechanical circulatory support , 2008, Expert review of cardiovascular therapy.

[10]  P. Colombo,et al.  Mechanical Circulatory Support for Cardiogenic Shock Complicating Acute Myocardial Infarction: An Experimental and Clinical Review , 2007, ASAIO journal.

[11]  N. Smedira,et al.  Improved survival after acute myocardial infarction complicated by cardiogenic shock with circulatory support and transplantation: comparing aggressive intervention with conservative treatment. , 2006, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[12]  W. Cohn,et al.  Initial experience with non-thoracic, extraperitoneal, off-pump insertion of the Jarvik 2000 Heart in patients with previous median sternotomy. , 2006, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[13]  M. Acker,et al.  Safety and efficacy of left ventricular assist device support in postmyocardial infarction cardiogenic shock. , 2006, The Annals of thoracic surgery.

[14]  G. Schuler,et al.  Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. , 2003, European heart journal.

[15]  R. Bolman,et al.  Left ventricular assist device bridge therapy for acute myocardial infarction. , 2000, The Annals of thoracic surgery.

[16]  J. Gurwitz,et al.  Temporal trends in cardiogenic shock complicating acute myocardial infarction. , 1999, The New England journal of medicine.

[17]  J. Alpert,et al.  Cardiogenic shock after acute myocardial infarction: Incidence and Mortality from a Community-Wide Perspective, 1975 to 1988 , 1991 .

[18]  Robert L Kormos,et al.  Second INTERMACS annual report: more than 1,000 primary left ventricular assist device implants. , 2010, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[19]  D. Burkhoff,et al.  CORONARY ARTERY DISEASE Original Studies Feasibility Study of the Use of the TandemHeart Percutaneous Ventricular Assist Device for Treatment of Cardiogenic Shock , 2006 .

[20]  L. Samuels,et al.  Improved survival with ventricular assist device support in cardiogenic shock after myocardial infarction. , 2003, The heart surgery forum.