Impact of preoperative hemodynamic support on early outcome in patients assisted with paracorporeal Thoratec® ventricular assist device

Background:Mechanicalcirculatorysupporthasbecomeawell-establishedprocedureforsomepatientswithcardiogenicshock.However,patient selectionandtimingofimplantationremainscritical.ThisretrospectivestudywasundertakentoidentifypreoperativepredictorsofsurvivalinICUof patients requiringmechanical circulatorysupport.Methods:Between1996 and 2006, 71patients(61 men,10women,aged41.6 12.2years)with primary cardiogenic shock were assisted using the paracorporeal Thoratec W VAD. Twenty-seven (38%) patients needed preoperative mechanical ventilation. Preoperative IV hemodynamic drug support included dobutamine in 63 (89%), vasopressors (adrenaline, noradrenaline or dopamine 5 mg/kg min) in 47 (66%), and intraaortic balloon counter-pulsation in 22 (31%) patients. Mean preoperative blood creatinine and total bilirubin levels were 162.2 72.4 mmol/l and 36.4 53.9 mmol/l, respectively. Results: Fifty-six (79%) patients required biventricular and 15 (21%) left ventricularsupport.Patientswereassistedforameandurationof73.1 93.6days(extremes,1—480days).Twenty-fivepatients(35%)diedwhileon support.Amongthese,18patients(25%)neverrecoveredsufficientlytoallowdismissalfromICU,anddiedafterameanof15.4 14.3days.Logistic regression identified preoperative IVadrenaline as sole predictor for ICU death(OR, 5.48; 95% CI, 1.45—20.7, p= 0.012). Conclusions:The need for preoperative IV adrenaline therapy appeared to be the sole independent risk factor for death in ICU in patients assisted with the Thoratec W paracorporeal VAD. This suggests that, besides hemodynamic and metabolic consequences of cardiogenic shock, preoperative activation of the inflammatory cascade could influence the prognosis of patients undergoing mechanical circulatory support. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.