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Ann Thorac Surg 1996;61:314-316
© 1996 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, Ruhr University of Bochum, Bad Oeynhausen, Germany
Abstract
Background. In spite of modern cardiac surgical techniques, severe cardiogenic shock not responding to pharmacologic therapy and intraaortic balloon pumping develops in about 0.2% to 1.2% of patients undergoing cardiac operations.
Methods. From September 1987 to September 1994, 184 patients were supported with different mechanical circulatory support systems. Nine patients with postcardiotomy cardiogenic shock were supported with the Thoratec ventricular assist device. Four patients suffered early postcardiotomy cardiogenic shock, and 5 patients suffered late postcardiotomy cardiogenic shock. In 6 patients the Thoratec device was applied exclusively, in 2 patients both Bio-Medicus and Thoratec, and in 1 patient both ABIOMED and Thoratec devices were used. Duration of support ranged from 5 to 46 days with a mean duration of 15 days.
Results. Four patients (44%) survived and were discharged. Main complications and causes of death were multiple organ failure and sepsis.
Conclusions. The results justify the use of Thoratec assist device in patients with severe preoperative cardiogenic shock.
The application of mechanical circulatory support in patients with postcardiotomy cardiogenic shock refractory to pharmacologic therapy and to intraaortic balloon pumping, which occurs in 0.2% to 1.2% of all patients undergoing cardiac operations [1–12], and as a bridge to transplantation [12–19] has become widely accepted in recent years. At our center we have up to now performed about 20,000 open heart procedures with an incidence of postcardiotomy cardiogenic shock of 0.6%.
Between September 1987 and September 1994 we supported 184 patients aged between 10 and 82 years with different mechanical circulatory support systems [2–6]. We started our mechanical circulatory support program with the application of a Bio-Medicus centrifugal pump (Bio-Medicus, Eden Prairie, MN), which until September 1994 was used in 61 patients. Fifty patients were treated with the ABIOMED BVS system 5000 (ABIOMED, Danvers, MA), 58 patients with the Thoratec ventricular assist device (Thoratec, Berkeley, CA), 12 patients with the Novacor left ventricular assist device (Novacor Division, Baxter Healthcare Corp, Oakland, CA), and 3 patients with the TCI device (Thermo Cardiosystems Inc, Woburn, MA). At present we have 14 patients under Novacor and 4 patients under TCI support. There were three main indications for support: postcardiotomy cardiogenic shock (n = 77), bridging to transplantation (n = 76), and a group of miscellaneous indications (n = 31), mainly patients suffering therapy-resistant acute myocardial infarction.
We report on 9 patients with postcardiotomy cardiogenic shock supported with the Thoratec ventricular assist device.
Material and Methods
Between October 1992 and September 1994, 9 patients (7 men, 2 women) between 43 and 65 years of age (mean, 51.9 years) with postcardiotomy cardiogenic shock refractory to pharmacologic therapy and intraaortic balloon pumping were supported with the Thoratec ventricular assist system. All of the patients had undergone coronary artery bypass grafting. Four patients (3 men, 1 woman) aged between 45 and 65 years (mean, 56.0 years) had suffered early postcardiotomy cardiogenic shock, which means that implantation of the device became necessary in the operating room, because the patients could not be weaned from extracorporeal circulation. In 5 patients (4 men, 1 woman) ranging between 43 and 62 years of age (mean, 48.6 years) late postcardiotomy cardiogenic shock occurred. In these patients the system was implanted in the intensive care unit after unsuccessful cardiopulmonary resuscitation. Our criteria for the implantation of mechanical circulatory support after cardiac operations have been published elsewhere. In 5 patients the Thoratec device was applied exclusively as left ventricular assistance. In 1 patient with late postcardiotomy cardiogenic shock and a body surface area of 2.2 m2 a sufficient cardiac output could not be achieved with the ABIOMED system, so we had to switch to the Thoratec device, which was applied for biventricular support. One patient with early postcardiotomy cardiogenic shock had been supported with the Bio-Medicus centrifugal pump at a referral hospital, but was subsequently switched to Thoratec left ventricular assistance because of irreversible left ventricular failure. He was subsequently transported to our center. Another patient was resuscitated in the intensive care unit under femorofemoral cardiopulmonary bypass, which was then replaced by Thoratec left ventricular support. In 6 patients left atrial cannulation and in 3 patients cannulation of the ventricular apex was performed. The patients are described in detail in Table 1
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Duration of support was 5 to 46 days, with a mean duration of 15 days. Of the 9 patients supported with the Thoratec system, 4 patients (44%) survived. Three of 4 patients with early postcardiotomy cardiogenic shock survived. One of them with exclusive application of the Thoratec device could be weaned from the device and discharged from the hospital. One patient, who had been supported with the Thoratec device for 36 days after 5 days of centrifugal pump assistance at a referral hospital in spite of Pseudomonas pneumonia, which resolved under Thoratec support, underwent successful transplantation and was discharged. The third patient could also be discharged after successful cardiac transplantation. One patient with early postcardiotomy cardiogenic shock died of multiple organ failure. Only 1 of 5 patients with late postcardiotomy cardiogenic shock underwent cardiac transplantation and survived. The other 4 patients of this subgroup died. The patient who had primarily been supported with the ABIOMED system died of multiple organ failure and sepsis on Thoratec support. The patient who had been resuscitated under femorofemoral cardiopulmonary bypass before being supported with the Thoratec device died of Pseudomonas pneumonia sepsis and multiple organ failure. Main complications as well as causes of death were multiple organ failure and sepsis. All patients who finally received transplants had recovered to New York Heart Association functional class I or II under ventricular support and survived.
Comment
Several devices for mechanical circulatory support have been developed to a stage where they are no longer investigational devices. On the basis of our experiences gathered with mechanical circulatory support in 184 patients since 1987 we use five different devices, the indications for which are as follows:
From September 1987 to September 1994, 77 patients with postcardiotomy cardiogenic shock received different devices for circulatory assistance (Table 2). The highest survival rate was achieved in the Thoratec group (44%), compared with 41% in the Bio-Medicus group and 37% in the ABIOMED group.
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The cannulation approach is decided on at the time of implantation. If the myocardial tissue turns out to be severely damaged and recovery cannot be expected, cannulation of the ventricular apex is preferred. However, if myocardial recovery seems to be possible, left atrial cannulation is performed.
The incidence of bleeding in the Thoratec group did not represent a major problem compared with patients supported with Bio-Medicus and ABIOMED devices. In the Thoratec group multiple organ failure and sepsis were the most frequent complications and causes of death.
Footnotes
Presented at The Third International Conference on Circulatory Support Devices for Severe Cardiac Failure, Pittsburgh, PA, Oct 28-30, 1994.
Address reprint requests to Dr El-Banayosy, Herzzentrum NRW, Klinik für Thorax- und Kardiovaskularchirurgie, Georgstr 11, D-32545 Bad Oeynhausen, Germany.
References
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