The Percutaneous Ventricular Assist Device in Severe Refractory Cardiogenic Shock

Study Questions:

What is the outcome of patients with refractory cardiogenic shock who are treated with tandem heart percutaneous ventricular assist device (pVAD)?

Methods:

The authors reported on 117 patients who underwent pVAD for refractory cardiogenic shock at their institution. Just under one-half of the patients (n = 56) received cardiopulmonary resuscitation (CPR) during or immediately before the time of implantation.

Results:

The underlying diagnosis was ischemic heart disease in 80 patients and nonischemic cardiomyopathy in 37 patients. Eighty patients had ischemic and 37 patients had nonischemic cardiomyopathy. Almost all patients had decompensation of chronic heart failure, with only five patients presenting with ST-elevation myocardial infarction. Implantation of the pVAD was associated with a significant improvement in cardiac index (median 0.52 L/min · m2 to 3.0 L/min · m2), systolic blood pressure (median 75-100 mm Hg), and mixed venous oxygen saturation (49-69%). The urine output increased from 70.7 ml/day to 1200 ml/day, and serum creatinine decreased from 1.5 mg/dl to 1.2 mg/dl. Thirty-one patients underwent left ventricular assist device (LVAD) placement and five underwent heart transplantation after pVAD insertion. One patient had a wire perforation of the left atrium and died after undergoing surgical repair. One patient required surgical repair of a groin complication. The mortality rate was 40% at 30 days and 45% 6 months.

Conclusions:

Use of tandem heart pVAD is associated with rapid improvement in patients with refractory cardiogenic shock.

Perspective:

The pVAD is an effective tool for providing hemodynamic support to patients in refractory cardiogenic shock. The strongest predictor of death in this study was the need for CPR prior to insertion of the device, and it is likely that survival would be better if pVAD insertion was considered earlier in the patient’s course. This study provides an important evidence context to guide care of these critically ill patients.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support

Keywords: Heart-Assist Devices, Cardiomyopathies, Heart Failure, Blood Pressure, Heart Transplantation


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