European Journal of Cardio-Thoracic Surgery Advance Access published January 5, 2015
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2015) 1–7 doi:10.1093/ejcts/ezu516
Extracorporeal life support as a bridge to bridge: a strategy to optimize ventricular assist device results Guillaume Lebretona,*, Matteo Pozzia,b, Ciro Mastroiannia, Philippe Légera, Alain Paviea and Pascal Leprincea a b
Division of Cardiac Surgery, Pitié-Salpêtrière Hospital, University ‘Pierre et Marie Curie’, Paris, France School in Cardiovascular Science, Cardiovascular Surgery Unit, University of Verona Medical School, Verona, Italy
* Corresponding author. Division of Cardiac Surgery, Pitié-Salpêtrière Hospital, University ‘Pierre et Marie Curie’, Paris 6, 47 Boulevard de l’Hôpital, Paris 75013, France. Tel: +33-142-162979; fax: +33-142-165639; e-mail: [email protected], [email protected] (G. Lebreton). Received 2 June 2014; received in revised form 19 November 2014; accepted 26 November 2014
Abstract OBJECTIVES: Extracorporeal life support (ECLS) devices provide temporary mechanical circulatory assistance and are usually implanted under emergency conditions in critical patients. If weaning off ECLS is not possible, heart transplantation or implantation of long-term mechanical circulatory support (LTMCS) is required. The purpose of our study was to evaluate the bridge-to-bridge (BTB) concept. METHODS: Between 1 January 2004 and 1 August 2010, 97 patients were assisted by LTMCS. The implantation was the first-line intervention in 48 patients (the bridge group), and was performed after a period of ECLS support in 49 others (the BTB group). RESULTS: The long-term survival rate was 51.6%, with a mean follow-up of 30.7 months, and there were no differences for biological parameters between the two groups. Patients in the BTB group whose condition was initially more severe, improved under ECLS support, and those in whom biological parameters did not revert to normal died after LTMCS. Risk factors for mortality in the BTB group were total bilirubin and lactate before LTMCS, and alkaline phosphatase before ECLS support. CONCLUSIONS: The BTB concept allows the implementation of LTMCS in severe patients, for whom it was not originally envisaged, with the same long-term survival as in first-line settings. ECLS in the evolution of patients is predictive of survival after LTMCS. Keywords: Heart failure • Heart-assist device • Extracorporeal circulation • Extracorporeal life support • Prognosis
INTRODUCTION Extracorporeal life support (ECLS) devices provide temporary mechanical circulatory assistance, are usually implanted under emergency conditions in critical patients, and can be utilized as a ‘bridge-to-recovery’, ‘bridge-to-transplantation’ or ‘bridge-tobridge’ (BTB), i.e. in patients on ECLS support awaiting long-term mechanical circulatory support (LTMCS) [1–4]. This phase of temporary assistance, while ensuring satisfactory haemodynamics, facilitates complementary diagnostic explorations that can guide the decision-making algorithm. Nevertheless, some authors have criticized the use of temporary assistance by ECLS with the aim of stabilizing the patient and recommend the implantation of an LTMCS device as the first-line therapeutic strategy [5, 6]. Of course, BTB is not a goal, but in our institution as well as in many others, we have to face emergent implantation of ECLS in patients with profound cardiogenic shock and because many of them will not recover, they will be candidates for BTB. Thus, the purpose of our study is to analyse the difference shown by BTB versus direct implantation of LTMCS patients at the time of implantation and try to understand if BTB is an efficient concept. We analysed the evolution of the biological profiles in these two
groups of patients in order to identify, among the BTB patients, the biological parameters that can be considered negative prognostic factors in terms of outcome during LTMCS, and thus to select those patients most suitable for a BTB strategy.
MATERIALS AND METHODS Study population Between 1 January 2004 and 30 April 2010, 817 patients were assisted by ECLS (veno-arterial ECMO) for cardiogenic shock: 420 were implanted using our Mobile Unit of Circulatory Support and, among these, LTMCS was subsequently established in 49 patients (the BTB group). Over the same period (Fig. 1), 48 patients were assisted by LTMCS utilized as the first-line therapeutic strategy (the ‘bridge’ group).
Indications for mechanical circulatory assistance A mechanical circulatory assistance device was implanted for cardiogenic shock in all cases. The different aetiologies of cardiogenic
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
TX & MCS
Cite this article as: Lebreton G, Pozzi M, Mastroianni C, Léger P, Pavie A, Leprince P. Extracorporeal life support as a bridge to bridge: a strategy to optimize ventricular assist device results. Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezu516.
2
G. Lebreton et al. / European Journal of Cardio-Thoracic Surgery
Table 1: Description of the population assisted by LTMCS between January 2004 and April 2010 at the Institute of Cardiology, Hospital of La Pitié-Salpêtrière (Paris)
Figure 1: General population of patients assisted by ECLS support between January 2004 and April 2010 at the Institute of Cardiology, Hospital of La Pitié-Salpêtrière (Paris).
shock are presented in Table 1. Every patient under mechanical circulatory assistance met the following criteria: (i) decompensated heart failure under inotropic support (epinephrine > 0.2 µg/kg/min or dobutamine > 20 µg/kg/min ± norepinephrine > 0.2 µg/kg/min) and/or need to increase the inotropic support and/or intra-aortic balloon pump; (ii) signs of cardiogenic shock (peripheral hypoperfusion, polypnoea, sweats, tachycardia, collapse, oligo/ anuria, abdominal pains, nausea, syncope, arrhythmias under inotropic support, ionic disorders, worsening of the hepatic and/or renal functions, wedge pressure >18 mmHg, cardiac index 8.45 >7.5
25 >1.45 >25
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2015) 1–7 doi:10.1093/ejcts/ezu516
Extracorporeal life support as a bridge to bridge: a strategy to optimize ventricular assist device results Guillaume Lebretona,*, Matteo Pozzia,b, Ciro Mastroiannia, Philippe Légera, Alain Paviea and Pascal Leprincea a b
Division of Cardiac Surgery, Pitié-Salpêtrière Hospital, University ‘Pierre et Marie Curie’, Paris, France School in Cardiovascular Science, Cardiovascular Surgery Unit, University of Verona Medical School, Verona, Italy
* Corresponding author. Division of Cardiac Surgery, Pitié-Salpêtrière Hospital, University ‘Pierre et Marie Curie’, Paris 6, 47 Boulevard de l’Hôpital, Paris 75013, France. Tel: +33-142-162979; fax: +33-142-165639; e-mail: [email protected], [email protected] (G. Lebreton). Received 2 June 2014; received in revised form 19 November 2014; accepted 26 November 2014
Abstract OBJECTIVES: Extracorporeal life support (ECLS) devices provide temporary mechanical circulatory assistance and are usually implanted under emergency conditions in critical patients. If weaning off ECLS is not possible, heart transplantation or implantation of long-term mechanical circulatory support (LTMCS) is required. The purpose of our study was to evaluate the bridge-to-bridge (BTB) concept. METHODS: Between 1 January 2004 and 1 August 2010, 97 patients were assisted by LTMCS. The implantation was the first-line intervention in 48 patients (the bridge group), and was performed after a period of ECLS support in 49 others (the BTB group). RESULTS: The long-term survival rate was 51.6%, with a mean follow-up of 30.7 months, and there were no differences for biological parameters between the two groups. Patients in the BTB group whose condition was initially more severe, improved under ECLS support, and those in whom biological parameters did not revert to normal died after LTMCS. Risk factors for mortality in the BTB group were total bilirubin and lactate before LTMCS, and alkaline phosphatase before ECLS support. CONCLUSIONS: The BTB concept allows the implementation of LTMCS in severe patients, for whom it was not originally envisaged, with the same long-term survival as in first-line settings. ECLS in the evolution of patients is predictive of survival after LTMCS. Keywords: Heart failure • Heart-assist device • Extracorporeal circulation • Extracorporeal life support • Prognosis
INTRODUCTION Extracorporeal life support (ECLS) devices provide temporary mechanical circulatory assistance, are usually implanted under emergency conditions in critical patients, and can be utilized as a ‘bridge-to-recovery’, ‘bridge-to-transplantation’ or ‘bridge-tobridge’ (BTB), i.e. in patients on ECLS support awaiting long-term mechanical circulatory support (LTMCS) [1–4]. This phase of temporary assistance, while ensuring satisfactory haemodynamics, facilitates complementary diagnostic explorations that can guide the decision-making algorithm. Nevertheless, some authors have criticized the use of temporary assistance by ECLS with the aim of stabilizing the patient and recommend the implantation of an LTMCS device as the first-line therapeutic strategy [5, 6]. Of course, BTB is not a goal, but in our institution as well as in many others, we have to face emergent implantation of ECLS in patients with profound cardiogenic shock and because many of them will not recover, they will be candidates for BTB. Thus, the purpose of our study is to analyse the difference shown by BTB versus direct implantation of LTMCS patients at the time of implantation and try to understand if BTB is an efficient concept. We analysed the evolution of the biological profiles in these two
groups of patients in order to identify, among the BTB patients, the biological parameters that can be considered negative prognostic factors in terms of outcome during LTMCS, and thus to select those patients most suitable for a BTB strategy.
MATERIALS AND METHODS Study population Between 1 January 2004 and 30 April 2010, 817 patients were assisted by ECLS (veno-arterial ECMO) for cardiogenic shock: 420 were implanted using our Mobile Unit of Circulatory Support and, among these, LTMCS was subsequently established in 49 patients (the BTB group). Over the same period (Fig. 1), 48 patients were assisted by LTMCS utilized as the first-line therapeutic strategy (the ‘bridge’ group).
Indications for mechanical circulatory assistance A mechanical circulatory assistance device was implanted for cardiogenic shock in all cases. The different aetiologies of cardiogenic
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
TX & MCS
Cite this article as: Lebreton G, Pozzi M, Mastroianni C, Léger P, Pavie A, Leprince P. Extracorporeal life support as a bridge to bridge: a strategy to optimize ventricular assist device results. Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezu516.
2
G. Lebreton et al. / European Journal of Cardio-Thoracic Surgery
Table 1: Description of the population assisted by LTMCS between January 2004 and April 2010 at the Institute of Cardiology, Hospital of La Pitié-Salpêtrière (Paris)
Figure 1: General population of patients assisted by ECLS support between January 2004 and April 2010 at the Institute of Cardiology, Hospital of La Pitié-Salpêtrière (Paris).
shock are presented in Table 1. Every patient under mechanical circulatory assistance met the following criteria: (i) decompensated heart failure under inotropic support (epinephrine > 0.2 µg/kg/min or dobutamine > 20 µg/kg/min ± norepinephrine > 0.2 µg/kg/min) and/or need to increase the inotropic support and/or intra-aortic balloon pump; (ii) signs of cardiogenic shock (peripheral hypoperfusion, polypnoea, sweats, tachycardia, collapse, oligo/ anuria, abdominal pains, nausea, syncope, arrhythmias under inotropic support, ionic disorders, worsening of the hepatic and/or renal functions, wedge pressure >18 mmHg, cardiac index 8.45 >7.5
25 >1.45 >25
