Ann Thorac Surg 2000;70:1259-1263
© 2000 The Society of Thoracic Surgeons
Original articles: cardiovascular
Bridge to recovery for postcardiotomy failure: is there still a role for centrifugal pumps?
Fredrick B.Y. Hoy, MDa,
Dale K. Mueller, MDa,
Dale M. Geiss, MDa,
James R. Munns, MDa,
Linda M. Bond, MAa,
Carol E. Linett, RN, BS, CCTCb,
Robert C. Gomez, MDa
a Division of Cardiovascular and Thoracic Surgery, OSF St. Francis Medical Center, Peoria, Illinois, USA
b Downstate Heart Transplant Center at OSF St. Francis Medical Center, Peoria, Illinois, USA
Address reprint requests to Dr Hoy, Illinois Cardiac Surgery Associates, 515 NE Glen Oak, Suite 202, Peoria, IL 61603
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Abstract
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Background. Early implantation of centrifugal devices in patients with postcardiotomy cardiogenic shock may provide a bridge to recovery and allow subsequent long-term survival.
Methods. Since January 1989, 62 patients were supported with centrifugal pumps because of failure to wean from cardiopulmonary bypass. Indications were postcardiotomy cardiogenic shock (PCCS) (n = 60), bridge to cardiac retransplantation (n = 1), and right ventricular failure (n = 1). Patients’ ages ranged from 23 to 78 years; 40 were men (65%), and 22 were women (35%). Twenty-two patients (35%) had a left ventricular assist device; 9 patients (15%) had a right ventricular assist device; and 31 patients (50%) had a biventricular assist device. Length of support ranged from 1 day to 19 days.
Results. Forty-two patients (68%) were weaned successfully; 27 patients survived to discharge (44%). Complications included bleeding (n = 41, 66%), renal failure (n = 28, 45%), and respiratory failure (n = 26, 42%). Currently, 23 patients survived 10 or more years (n = 1), 6 to 10 years (n = 7), 1 to 5 years (n = 10), and less than 1 year (n = 5).
Conclusions. Centrifugal pumps are available, easy to use, and relatively inexpensive. Our experience justifies their continued use as a bridge to recovery for patients with postcardiotomy cardiogenic shock, despite the availability and increasing use of more expensive devices.
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Introduction
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Postcardiotomy cardiogenic shock (PCCS) is rare, occurring in 2% to 6% of all patients who undergo myocardial revascularization or valvular heart operations [1]. Although advances in cardiac surgical techniques and myocardial protection occur continually, approximately 1% of patients who have cardiac operations will not be weaned successfully from cardiopulmonary bypass (CPB) [2]. However, some PCCS patients treated in a timely fashion with circulatory assist devices might recover from an otherwise fatal condition [1–15]. If a reversible myocardial injury occurs during a cardiac surgical procedure, myocardial function might improve if the workload on the myocardium is reduced [3]. The physiologic objective of a ventricular assistance device (VAD) is to unload the failing ventricle and provide temporary circulatory support of the vital organs as the injured myocardium recovers [4]. Roller pumps, centrifugal pumps, and a variety of pneumatically and electrically driven devices currently are used as mechanical VADs [1–16].
At our institution, since 1989, the Bio-Medicus centrifugal system (Bio-Pump; Bio-Medicus, Eden Prairie, MN) has been the preferred VAD as a bridge to recovery for patients with postcardiotomy failure because it is user-friendly, available, relatively inexpensive, and easy to implant and explant. We found that when patients receive early continuous flow (nonpulsatile) support of a centrifugal device, they often show clinical improvement and subsequent long-term survival. Other reports confirm that the use of centrifugal devices can lead to successful outcomes and satisfactory long-term survival in approximately one third or more of patients [1, 4–6].
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Patients and methods
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Demographics and patient assessment
Since January 1989, 62 patients have had centrifugal pumps implanted because of failure to wean from CPB after cardiovascular procedures. This represents 0.5% of patients who had surgical procedures during that time period. Use of a VAD was not a substitute for a less-than-complete surgical procedure. As a rule, candidates for VADs were less than 80 years old and had no coexisting significant medical problems (eg, dialysis dependency, malignancy, etc). All patients initially were supported with appropriate pharmacologic agents and nearly all (99%) had concurrent intraaortic balloon pumps in place. The indications for ventricular support were postcardiotomy cardiogenic shock (n = 60), as a bridge to cardiac retransplantation (n = 1), and right ventricular failure, resulting from a pulmonary embolectomy in a post–renal transplant patient (n = 1). The patients’ ages ranged from 23 years to 78 years. Forty patients were male (65%), ranging in age from 23 to 78 years, with a mean age of 62.4 years ± 10.9 standard deviation (SD). Twenty-two patients were female (35%), ranging in age from 41 to 75 years, with a mean age of 61.4 years ± 9.3 SD. The mean age at VAD implantation was 62 years ± 10.2 SD. The predominant operative procedure was coronary artery bypass (n = 59), which alone or combined with other procedures constituted 95% of the operations (Table 1). The need for support with a left ventricular assist device (LVAD) occurred in 22 patients (35%), a right ventricular assist device (RVAD) in 9 patients (15%), and a biventricular assist device (BVAD) in 31 patients (50%). The duration of support ranged from 1 day to 19 days (Fig 1).
Operative technique
Left ventricular support was accomplished by insertion of a 24 or 28F angled cannula into the left atrium through a pledgeted suture in the right superior pulmonary vein. A second cannula was then inserted into the ascending aorta. Both cannulas were brought through stab wounds in the epigastrium. Right ventricular support was accomplished by inserting a cannula in the right atrium (and occasionally through the tricuspid valve into the right ventricle) and the outflow cannula into the pulmonary artery. Pump flows usually averaged 4.0 to 5.0 L/minute. Systemic heparinization was not begun until weaning. An attempt was made to close the sternum in all patients.
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Results
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The overall rate of weaning from mechanical support was 68% (n = 42); 27 patients (44%) were weaned and survived to discharge from the hospital (Fig 2). Of the 40 men, 17 (43%) survived to discharge, and 10 (45%) of the 22 women survived to discharge. Twenty patients died while on a VAD; 15 patients were weaned and subsequently died. The type of circulatory assist device (LVAD, RVAD, BVAD) and associated wean and survival to discharge data are shown in Figure 3. Biventricular assistance was not associated with a higher mortality rate than univentricular assistance. The most prevalent complications with the use of mechanical support were bleeding (n = 41, 66%), renal failure (n = 28, 45%), and respiratory failure (n = 26, 42%) (Table 2). In patients who did not survive, the time from weaning to death generally occurred in 1 day or less, reflecting irreversible complications and VAD discontinuation (Fig 4). The three predominant causes of death while a patient was on a device or after weaning included renal failure (n = 22, 63%), univentricular or biventricular failure (n = 18, 51%), and respiratory failure (n = 16, 46%) (Table 3).
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Fig 3. Type of ventricular assist device. (BVA = biventricular assist; LVA = left ventricular assist; RVA = right ventricular assist.)
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Fig 4. Patients’ length of hospital stay from weaning to death. Numbers indicate patients weaned but not discharged.
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Follow-up is limited to 10 years. During that time, 4 patients have died; their length of survival was 6.1, 4.0, 1.9, and 1.3 years after discharge. At present, 23 patients survive. Their overall length of survival after hospital discharge is more than 10 years (n = 1); 6 to 10 years (n = 7); 1 to 5 years (n = 10); and less than 1 year (n = 5).
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Comment
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Of critical importance in the initial stage of postcardiotomy failure is early implantation of ventricular assistance, insertion of an intraaortic balloon pump to maintain pulsatile perfusion, and supporting the right ventricle. Right ventricular failure is more likely to occur if multiple transfusions are required. Obtaining hemostasis after VAD implantation is particularly important and is facilitated by aprotinin or other fibrinolytic agents. Heparin-bonded circuits have been used recently. With good hemostasis, volume replacement is kept to a minimum and nursing care in the intensive care unit is made easier. While in the intensive care unit, prompt initiation of nutritional support, respiratory care, and physical therapy are essential for successful weaning and good outcome. The weaning process usually begins 3 to 4 days after VAD implantation. Generally, VADs are weaned 1.0 L every 24 hours at 250 mL/minute increments down to 2.0 L and then heparin is begun. During the weaning process, transesophageal echocardiography is helpful in determining myocardial recovery.
Although we have had relatively successful outcomes with centrifugal pumps, several disadvantages are associated with their use. Primarily, there is the need for intraaortic balloon pumping to obtain a pulsatile flow pattern. In addition, centrifugal pumps provide a limited length of circulatory support. The maximum duration of their use is usually 2 weeks. Patients cannot be ambulatory during this time and are at risk of developing respiratory and renal problems, infection, and thrombosis. Similar outcomes and disadvantages also can occur with pneumatic devices.
Several studies [1–9, 14–16] have used both centrifugal and pneumatic devices in PCCS patients and reported outcomes such as days on support, weaning rates, survival to discharge rates, and associated complications (Table 4). A composite of reported centrifugal pump usage (Table 4) shows an average duration of 3.5 to 4.0 days on support, a weaning rate of 50% to 65%, and a survival to discharge rate of 20% to 45%. The predominant complications reported with centrifugal pumps were bleeding (45% to 87%), renal failure (18% to 45%), and neurologic incidents (12% to 33%). Bleeding was the major complication associated with centrifugal support [2, 5, 7, 8,]. Researchers who used centrifugal pumps noted outcomes that were comparable to those of pneumatic devices and concluded that centrifugal pumps were easy to use and offered an economic, effective approach for short-term circulatory support [1–9].
A composite of pneumatic pulsatile pump usage (Table 4) shows an average duration of 4.7 to 5.2 days on support, an average weaning rate of 55%, and an average survival to discharge rate of 29%. Predominant complications associated with their use were bleeding (76%), renal failure (52%), and neurologic incidents (26%). The advantages of pulsatile pneumatic devices included possible reduction of inotropic support, no need for intraaortic counterpulsation, possibly improved organ perfusion, and capability for prolonged use when necessary [7, 15, 16]. Systemic anticoagulation can be a possible disadvantage of certain pulsatile devices [7]. The incidence of renal failure, hemolysis, technical problems, and infection might be higher with pneumatic device support [2]. Pae and associates [1] noted that infection statistically increased with the use of pneumatic devices, possibly related to the extended number of days on pneumatic circulatory support compared with centrifugal support.
In a registry series, Pae and associates [1] analyzed weaning and survival to discharge rates of 965 PCCS patients after implantation of nonpulsatile centrifugal and pulsatile pneumatic devices. They reported no significant difference in wean to survival rates between the two groups of patients [1]. Although univentricular support had the most favorable wean to discharge results, mode of support did not appear to be statistically related to long-term survival after weaning [1]. Mehta and associates [2] noted that patients had significantly shorter periods of support with centrifugal devices (mean 2.9 days) than with pneumatic devices (mean 6.5 days). They also found no significant difference in weaning and survival to discharge rates between patients who had centrifugal support and those with pneumatic devices [2].
Most authors reported that a significant increase in complications occurred after 7 to 10 days of circulatory support [3]. Longer time on CPB before VAD implantation appeared to reduce weaning from circulatory support and subsequent hospital discharge rates [2]. Furthermore, patients who were weaned, but who did not survive to discharge, also had significantly longer time on circulatory support [2]. Advanced age also appeared to be a relative contraindication to ventricular assistance [4]. Weaning without discharge was usually attributed to advanced age and subsequent renal failure [1, 2]. When necessary, Wareing and Kouchoukos [3] advocated using the centrifugal pump in older patients with PCCS.
There is limited information regarding the use of the Thoratec (Thoratec, Berkeley, CA), HeartMate (Thermo Cardiosystems, Woburn, MA), Novacor (Novacor Division, Baxter Healthcare Corp, Oakland, CA), and the Hemopump (Johnson & Johnson Interventional Systems, Rancho Cordova, CA) as bridge-to-recovery devices in PCCS patients. Korfer and associates [10] reported a small series of nine patients implanted with a Thoratec device for PCCS; 4 patients (44%) survived, 1 was weaned and discharged, and 3 went on to transplant. The predominant complications and causes of death in their series were sepsis and multiple organ failure [10]. Several authors have had successful outcomes with their use of the Hemopump. Wampler and associates [11] reported significant hemodynamic support and minimal hemolysis with the Hemopump, including a 30-day overall survival rate of 31.7%. Wiebalck and associates [12] reported similar findings with their use of the Hemopump, as well as a 58% survival and hospital discharge rate. Dreyfus [13] reported an overall survival rate of 40% with the Hemopump, and recommended its immediate use in the operating room as a first step to treat postcardiotomy shock before a medical or intraaortic balloon pump failure.
Our experience with the use of centrifugal pumps as a bridge to recovery for patients with postcardiotomy failure has been favorable. Many patients in our series showed clinical improvement with circulatory support, were weaned successfully and discharged from the hospital, and have had satisfactory long-term survival. Centrifugal pumps are available, easy to use, relatively inexpensive, and often have outcomes equivalent to pneumatic devices. Our experience justifies their continued use as a bridge to recovery for PCCS patients, despite the availability and the increasing use of more expensive devices.
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References
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Mehta S.M., Aufiero T.X., Pae W.E., Jr, Miller C.A., Pierce W.S. Results of mechanical ventricular assistance for the treatment for post cardiotomy cardiogenic shock. ASAIO J 1996;42:211-218.[Medline]
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Accepted for publication April 4, 2000.
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Top
Abstract
Introduction
