Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts.
The University of Alabama at Birmingham, Birmingham, Alabama.
J Heart Lung Transplant. 2020 Apr;39(4):342-352. doi: 10.1016/j.healun.2019.12.011. Epub 2020 Jan 21.
Patients with cardiogenic shock (CS) needing temporary circulatory support (TCS) have poor survival rates after implantation of durable ventricular assist device (dVAD). We aimed to characterize post-dVAD adverse event burden and survival rates in patients requiring pre-operative TCS.
We analyzed 13,511 adults (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] Profiles 1-3) with continuous-flow dVADs in International Society for Heart and Lung Transplantation Registry for Mechanically Assisted Circulatory Support (2013-2017) according to the need for pre-operative TCS (n = 5,632) vs no TCS (n = 7,879). Of these, 726 (5.4%) had biventricular assist devices (BiVAD). Furthermore, we compared prevalent rates (events/100 patient-months) of bleeding, device-related infection, hemorrhagic and ischemic cerebrovascular accidents (hemorrhagic cerebral vascular accident [hCVA], and ischemic cerebral vascular accident [iCVA]) in early (<3 months) and late (≥3 months) post-operative periods.
TCS included extracorporeal membrane oxygenation (ECMO) (n = 1,138), intra-aortic balloon pump (IABP) (n = 3,901), and other TCS (n = 593). Within 3 post-operative months, there were more major bleeding and cerebrovascular accidents (CVAs) in patients with pre-operative ECMO (events/100 patient-months rates: bleeding = 19, hCVA = 1.6, iCVA = 2.8) or IABP (bleeding = 17.3, hCVA = 1.5, iCVA = 1.5) vs no TCS (bleeding = 13.2, hCVA = 1.1, iCVA = 1.2, all p < 0.05). After 3 months, adverse events were lower and similar in all groups. Patients with ECMO had the worst short- and long-term survival rates. Patients with BiVAD had the worst survival rate regardless of need for pre-operative TCS. CVA and multiorgan failures were the common causes of death for patients with TCS and patients without TCS.
Patients requiring TCS before dVAD had a sicker phenotype and higher rates of early post-operative adverse events than patients without TCS. ECMO was associated with very high early ischemic stroke, bleeding, and mortality. The extreme CS phenotype needing ECMO warrants a higher-level profile status, such as INTERMACS "0."
需要临时循环支持（TCS）的心源休克（CS）患者在植入耐用心室辅助装置（dVAD）后生存率较低。我们旨在描述术前需要 TCS 的患者在植入 dVAD 后的不良事件负担和生存率。
我们分析了国际心肺移植协会机械循环支持注册中心（2013-2017 年）13511 名接受连续流 dVAD 的成年人（INTERMACS 分级 1-3），根据术前 TCS 的需求（n=5632）和未接受 TCS（n=7879）进行分组。其中，726 名（5.4%）患者使用了双心室辅助装置（BiVAD）。此外，我们比较了早期（<3 个月）和晚期（≥3 个月）术后不同时间段内出血、器械相关感染、出血性和缺血性脑血管意外（出血性脑血管意外[hCVA]和缺血性脑血管意外[iCVA]）的常见发生率（每 100 患者-月的事件数）。
TCS 包括体外膜氧合（ECMO）（n=1138）、主动脉内球囊泵（IABP）（n=3901）和其他 TCS（n=593）。术后 3 个月内，术前使用 ECMO（事件/100 患者-月发生率：出血 19，hCVA 1.6，iCVA 2.8）或 IABP（出血 17.3，hCVA 1.5，iCVA 1.5）的患者发生重大出血和 CVA 的概率高于未接受 TCS（出血 13.2，hCVA 1.1，iCVA 1.2，均 P<0.05）。3 个月后，所有组的不良事件发生率较低且相似。使用 ECMO 的患者短期和长期生存率最差。无论是否需要术前 TCS，使用 BiVAD 的患者生存率最差。TCS 和未接受 TCS 的患者的常见死亡原因是 CVA 和多器官衰竭。
需要在 dVAD 前接受 TCS 的患者比未接受 TCS 的患者病情更严重，术后早期不良事件发生率更高。ECMO 与极高的早期缺血性卒中和出血以及死亡率相关。需要 ECMO 的极端 CS 表型需要更高水平的 Profile 状态，如 INTERMACS“0”。
