Early planned institution of biventricular mechanical circulatory support results in improved outcomes compared with delayed conversion of a left ventricular assist device to a biventricular assist device.

OBJECTIVE: It is generally accepted that patients who require biventricular assist device support have poorer outcomes than those requiring isolated left ventricular assist device support. However, it is unknown how the timing of biventricular assist device insertion affects outcomes. We hypothesized that planned biventricular assist device insertion improves survival compared with delayed conversion of left ventricular assist device support to biventricular assist device support. METHODS: We reviewed and compared outcomes of 266 patients undergoing left ventricular assist device or biventricular assist device placement at the University of Pennsylvania from April 1995 to June 2007. We subdivided patients receiving biventricular assist devices into planned biventricular assist device (P-BiVAD) and delayed biventricular assist device (D-BiVAD) groups based on the timing of right ventricular assist device insertion. We defined the D-BiVAD group as any failure of isolated left ventricular assist device support. RESULTS: Of 266 patients who received left ventricular assist devices, 99 (37%) required biventricular assist device support. We compared preoperative characteristics, successful bridging to transplantation, survival to hospital discharge, and Kaplan-Meier 1-year survival between the P-BiVAD (n = 71) and D-BiVAD (n = 28) groups. Preoperative comparison showed that patients who ultimately require biventricular support have similar preoperative status. Left ventricular assist device (n = 167) outcomes in all categories exceeded both P-BiVAD and D-BiVAD group outcomes. Furthermore, patients in the P-BiVAD group had superior survival to discharge than patients in the D-BiVAD group (51% vs 29%, P < .05). One-year and long-term Kaplan-Meier survival distribution confirmed this finding. There was also a trend toward improved bridging to transplantation in the P-BiVAD (n = 55) versus D-BiVAD (n = 22) groups (65% vs 45%, P = .10). CONCLUSION: When patients at high risk for failure of isolated left ventricular assist device support are identified, proceeding directly to biventricular assist device implantation is advised because early institution of biventricular support results in dramatic improvement in survival.

Risk score derived from pre-operative data analysis predicts the need for biventricular mechanical circulatory support.

BACKGROUND: Right ventricular (RV) failure after left ventricular assist device (LVAD) placement is a serious complication and is difficult to predict. In the era of destination therapy and the total artificial heart, predicting post-LVAD RV failure requiring mechanical support is extremely important. METHODS: We reviewed patient characteristics, laboratory values and hemodynamic data from 266 patients who underwent LVAD placement at the University of Pennsylvania from April 1995 to June 2007. RESULTS: Of 266 LVAD recipients, 99 required RV assist device (BiVAD) placement (37%). We compared 36 parameters between LVAD (n = 167) and BiVAD patients (n = 99) to determine pre-operative risk factors for RV assist device (RVAD) need. By univariate analysis, 23 variables showed statistically significant differences between the two groups (p < or = 0.05). By multivariate logistic regression, cardiac index < or =2.2 liters/min/m(2) (odds ratio [OR] 5.7), RV stroke work index < or =0.25 mm Hg . liter/m(2) (OR 5.1), severe pre-operative RV dysfunction (OR 5.0), pre-operative creatinine > or =1.9 mg/dl (OR 4.8), previous cardiac surgery (OR 4.5) and systolic blood pressure < or =96 mm Hg (OR 2.9) were the best predictors of RVAD need. CONCLUSIONS: The most significant predictors for RVAD need were cardiac index, RV stroke work index, severe pre-operative RV dysfunction, creatinine, previous cardiac surgery and systolic blood pressure. Using these data, we constructed an algorithm that can predict which LVAD patients will require RVAD with >80% sensitivity and specificity.

Safety and efficacy of left ventricular assist device support in postmyocardial infarction cardiogenic shock.

BACKGROUND: Cardiogenic shock secondary to acute myocardial infarction (CS-AMI) is the leading cause of death in all acute coronary syndromes. Experience with the use of left ventricular assist devices (LVADs) in patients with CS-AMI is limited. One of the surgical dilemmas when implanting an LVAD into a patient with an acute anterior wall myocardial infarction is the safety of apical cannulation. We present a decade of experience with the use of LVAD with apical cannulation in patients with CS-AMI. METHODS: A retrospective review of the ventricular assist device (VAD) database at the Hospital of the University of Pennsylvania was instituted. RESULTS: From April 1995 to February 2005, 49 patients received LVAD support for CS-AMI (group I). The majority of these patients suffered anterior wall myocardial infarctions. This group of patients was compared with a separate cohort of 61 patients with chronic ischemic cardiomyopathy who received LVAD support (group II). The VAD support successfully bridged 38 (74%) group I patients and 37 (61%) group II patients to heart transplantation. Of the 38 patients transplanted in group I, 33 (87%) were discharged from the hospital. In group II, 36 of the 37 patients transplanted (97%) survived to hospital discharge. The overall in-hospital mortality rates for the series were 33% for group I patients, and 41% for group II patients. CONCLUSIONS: Left ventricular assist device support in patients with CS-AMI is a safe and effective therapy which should be incorporated into the standard treatment paradigm for appropriate patients presenting with this lethal disease.