Which critical hemodynamic patients should be considered for VAD implantation?

Objectives: Poor survival has been demonstrated after VAD implantation for INTERMACS profile 1 and 2 patients compared with more stable levels. However, risk factors of this high risk cohort have not been determined so far. The aim of the present study was to identify determinants associated with this very high mortality rate.

Methods: Between February 1993 and January 2013 158 hemodynamic critical patients out of 298 underwent VAD implantation in our institution. Hemodynamic critical patients were defined as patients in INTERMACS Level of 1 (109 pts) or INTERMACS Level of 2 (49 pts) respectively. Assist devices implanted were: HVAD Heartware n = 18; INCOR n = 11; VENTRASSIST n = 2; DE BAKEY n = 22 and pulsatile systems n = 105.

Results: After cumulative support duration of 815.35 months Kaplan-Meier analysis revealed a survival of 63.9%, 48.8%, and 40.3% at 1, 6, and 12 months, respectively. Cox regression analyses identified age > 50 (p = 0.001, OR 2.48), WBC count > 13.000/µl (p = 0.01, OR 2.06), preoperative renal replacement therapy (p = 0.001, OR 2.63) and postcardiotomy failure (p < 0.001, OR 2.79) as independent predictors of mortality. Of note, last generation VADs were not associated with significantly 6 month better survival (p = 0.59). Patients without the aforementioned risk factors could yield a survival of 79.2% at 6 months.

Conclusions: This single-center experience shows that VAD implantation in hemodynamic unstable patients generally results in early poor outcome, even in third generation pumps. However, avoiding the aforementioned risk factors survival could result in improved outcome.