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Ann Thorac Surg 1999;68:662-665
© 1999 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
Address reprint requests to Dr Kitamura, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162, Japan
Presented at the Fourth International Conference on Circulatory Support Devices for Severe Cardiac Failure, Houston, TX, Oct 3–5, 1997.
Abstract
Background. After open heart operations about 1% of patients still need temporary circulatory support for severe cardiac failure, and over half of those patients die during or after the support. This study assessed the efficacy of the current strategy of circulatory support.
Methods. We assessed clinical outcome of 64 consecutive patients (1.5% of pump cases) who had temporary circulatory support associated with perioperative variables. The results were analyzed by logistic regression analysis.
Results. The weaning and discharge rates were 50.0% and 26.7% with venoarterial bypass, 76.2% and 57.1% with biventricular bypass, 87.5% and 37.5% with isolated left ventricular bypass, and 60.0% and 40.0% with pulsatile left ventricular assistance, respectively. Logistic regression analysis identified presupport cardiogenic shock (odds ratio, 9.922) and support type (14.684) as factors significantly associated with nonweaning from the temporary support, and cardiogenic shock (28.268), support duration (2.948), and support type (14.184) as factors significantly associated with mortality during or after the circulatory support.
Conclusions. The current strategy of temporary circulatory support improved clinical outcome of patients with severe cardiac failure. Early application of circulatory support before profound cardiogenic shock and proper selection of the support type might be key factors for successful circulatory support postoperatively after operation.
Recently, short-term and long-term outcome after cardiac operations has improved because of standardized surgical techniques, sufficient myocardial protection, and precise management of patients during and after operation. However, about 1% of patients who have open heart operations still need mechanical circulatory support for severe cardiac dysfunction [1, 2]. Various blood pumps, such as centrifugal pumps and pneumatic pulsatile pumps, have been used as temporary circulatory support for recovery of damaged myocardium. Clinical results of the temporary support have also improved recently. Nonetheless, more than half of the postoperative patients with circulatory support die during or after the support in the hospital [1–3]. Many perioperative factors are presumed to affect final outcome of the temporary circulatory support. In this investigation, we assessed clinical results of the current strategy of temporary circulatory support for severe cardiac failure after operation.
Material and methods
Between January 1984 and March 1997, 4,142 adults with heart diseases underwent cardiac operations using cardiopulmonary bypass at our institution. Of them, 64 patients (1.5% of pump cses) needed temporary circulatory support for severe cardiac failure. Age of the patients ranged from 22 to 78 years (mean 53.7 years). There were 40 men and 24 women. Heart disease was valvular in 37 patients, ischemic in 25 patients, and congenital in 2 patients. All patients had profound heart failure or fatal ventricular arrhythmia and required circulatory support for life-saving measures.
The temporary circulatory support was applied when peak arterial pressure was less than 80 mm Hg, mean left atrial (or pulmonary capillary wedge) pressure was more than 18 mm Hg, and cardiac index was less than 1.8 L/m2 per minute, or fatal ventricular arrhythmia repeatedly occurred despite maximum pharmacologic treatments and intra-aortic balloon pump (IABP) support.
According to the patient’s practical condition, we applied various types of circulatory support as follows. Venoarterial bypass (VAB) with oxygenation was used for acute cardiac failure with respiratory insufficiency, and biventricular bypass (BVB) [4] was applied for left-dominant biventricular failure. Left ventricular bypass (LVB) or a left ventricular assist device (LVAD) was used for isolated left ventricular failure. As a new technique of emergency VAB, percutaneous cardiopulmonary support (PCPS) [5, 6] was used mainly for acute cardiogenic shock after weaning from standard cardiopulmonary bypass, and it would be converted to BVB, LVB, or LVAD if necessary. Regarding blood pumps for the temporary support, a Bio-Medicus centrifugal pump (Medtronic Bio-Medicus, Eden Prairie, MN) was used mainly for VAB, BVB, and LVB, and a Zeon pneumatic pulsatile pump (Zeon Medical Inc, Tokyo, Japan) was as LVAD. The Terumo emergency bypass system (Terumo Co, Tokyo, Japan) was used for PCPS. Concerning drive control of the pulsatile LVAD, we used the combined counter-pulsation drive of the LVAD and IABP [7] by means of an electrocardiographic trigger. In this method, ejection of the LVAD was controlled in the early diastole of the native heart and inflation of the IABP was set in the late diastole. This drive control is supposed to be effective for maximum reduction of afterload of the native left ventricle and to improve coronary circulation of the failing heart.
In this study, we assessed clinical results of temporary circulatory support associated perioperative variables, and the main outcome variables were analyzed by logistic regression analysis. For this multivariate analysis, age and gender of patients, New York Heart Association functional class, category of heart disease, left ventricular ejection fraction, history of previous cardiac operations, and dysfunction of other organs were selected as preoperative variables. Surgical procedure, length of operation, aortic cross-clamp time, presupport cardiogenic shock, ventricular fibrillation, type of circulatory support, and support duration were evaluated as operative variables. Probability value less than 0.05 was considered to be significant.
Results
Of the 64 patients who required mechanical support after cardiac operation, 30 had VAB with oxygenation, 21 had BVB, 8 had the LVB, and the remaining 5 patients received a pulsatile LVAD. Eight patients with PCPS (emergency VAB) were included in the VAB group. Duration of the circulatory support ranged from 3 to 312 hours (mean, 32.3 hours).
With respect to category of heart disease, of 37 patients with valvular heart disease, 23 (59.0%) were weaned from the support and 16 (43.2%) were discharged from the hospital. Of 25 patients with ischemic heart disease, 17 (68.0%) were weaned and 8 (32.0%) survived, and 1 of 2 patients with congenital heart disease was weaned and discharged from the hospital.
Table 1 shows clinical results of the temporary circulatory support by type of support. The weaning and discharge rates were 50.0% and 26.7% with VAB, 76.2% and 57.1% with BVB, 87.5% and 37.5% with LVB, and 60.0% and 40.0% with LVAD, respectively. The weaning rate was higher in the patients with LVB or BVB, but the discharge rate was better in patients after weaning from BVB or LVAD. Both rates of the VAB group (including emergency PCPS) were the lowest of the four groups. Overall outcomes of the temporary circulatory support in this series of patients were 64.1% weaning rate and 39.1% discharge rate.
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We compared clinical outcome of the patients with and without presupport cardiogenic shock with regard to hemodynamic condition at the introduction of circulatory support. Severe hypotension less than 70 mm Hg or ventricular fibrillation which required cardiac resuscitation was defined as presupport cardiogenic shock. Twelve (48.0%) of 25 patients who received circulatory support after profound cardiogenic shock could be weaned from support, but only 1 patient (4.0%) was alive without brain damage and discharged from the hospital. Of 39 patients without cardiogenic shock in whom circulatory support was initiated, 29 (74.4%) were weaned and 24 (61.5%) survived.
Major and fatal complications are listed in Table 2. With respect to complications of temporary circulatory support, massive bleeding and malignant ventricular arrhythmia (or immature weaning) were less frequent with low-heparinized isolated left ventricular support (LVB or LVAD). However, intractable biventricular failure, infection, and multiple organ failure still remain significant complications with any type of circulatory support.
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From the information in the combined registry (ASAIO-ISHLT) [1], 1,279 patients had temporary circulatory support after cardiac operation as of December 1993, and 584 patients (45.7%) were weaned from the support. Of those 323 patients (25.3%) were discharged from the hospital. Similar results were reported from the Japanese registry for the clinical use of ventricular assist devices [8]. Between May 1980 and August 1997, 279 patients had temporary circulatory support with ventricular assist devices, and 128 patients (46.2%) were weaned from the support and 72 (26.0%) survived. Regarding the condition of patients, 198 patients (71.0%) were dependent on cardiopulmonary bypass, 61 patients (21.9%) had low cardiac output syndrome, and the remaining 20 patients (7.2%) showed cardiogenic shock. The weaning and discharge rates were equivalent for those three conditions.
Approximately 1% of patients who have open heart operations show severe cardiac failure despite IABP and inotropic support and need mechanical circulatory support [1–3]. In the present study, 64 (1.5%) of 4,142 adults who had cardiac operations using bypass required circulatory support for postcardiotomy cardiac failure. All patients showed severe cardiac failure or fatal ventricular arrhythmia even with appropriate inotropic support and IABP assistance.
Our current strategy of temporary circulatory support for severe postoperative cardiac failure consists of combined use of VAB, BVB, LVB, and LVAD. First, patients with low cardiac output are treated by pharmacologic support and IABP. If the patients are unable to be weaned from cardiopulmonary bypass, VAB with oxygenation is maintained for evaluation of left and right ventricular performance and respiratory function. In cases of left-dominant biventricular failure, BVB is applied for balanced support of both ventricles. Short-term LVB or intermediate-term LVAD is selected for isolated left ventricular failure. In emergency situations, such as sudden onset of cardiogenic shock in the intensive care unit after operation, PCPS is the support of choice for saving brain, heart, and other organs. After hemodynamic stabilization is attained, the appropriate type of circulatory support will be selected for sufficient recovery of the left or right ventricle or both. Although this strategy was successful, with a 64.1% weaning rate and a 39.1% discharge rate, some patients with profound biventricular failure needed more long-term biventricular assistance [9, 10]. Quick evaluation of the emergency grade and functional assessment of both ventricles and other organs is essential for proper application of the temporary circulatory support for severe cardiac failure after operation.
Regarding the results of the logistic regression analysis in this investigation, selected independent factors that attained statistical significance were presupport cardiogenic shock and support type for nonweaning and cardiogenic shock, support type, and duration of support for in-hospital death. In clinical treatment of patients with postcardiotomy cardiogenic shock, PCPS is the fastest support for saving brain, heart, and other major organs, and stepwise conversion to advanced circulatory support is important for effective recovery of the failing heart.
From this retrospective study of 64 patients, we suspect that patients who died during or after some types of temporary support might have been saved by earlier or more appropriate conversion to other types of circulatory support. In terms of the temporary circulatory support after operation, our technique of BVB support [4] appeared to be useful for assessing the grade and type of cardiac failure with or without pulmonary failure. Therefore, all 30 patients with VAB could be candidates for BVB. Concerning the type of cardiac failure in each patient, the type of failure was changed easily during the immediate postoperative period, and proper conversion of the temporary support might be a key factor for effective recovery of left or right ventricle and lungs.
The data from this investigation suggest that our current strategy of temporary circulatory support for severe cardiac failure showed some improvement of clinical results, but early and proper conversion to more advanced ventricular assist devices might be needed for saving the patients with intractable biventricular failure.
References
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Y. Oishi, M. Masuda, K.-i. Imasaka, S. Morita, and H. Yasui Limitation of Venoarterial Bypass. Early Predictor and Optimal Conversion Asian Cardiovasc Thorac Ann, June 1, 2005; 13(2): 167 - 171. [Abstract] [Full Text] [PDF]
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 M. E. Stone, W. Soong, M. Krol, and D. L. Reich The Anesthetic Considerations in Patients with Ventricular Assist Devices Presenting for Noncardiac Surgery: A Review of Eight Cases Anesth. Analg., July 1, 2002; 95(1): 42 - 49. [Abstract] [Full Text] [PDF]
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