Bridging INTERMACS Profile 1 Patients to Left Ventricular Assist Device: The Right Device, the Right Time, and the Best Surgical Approach

Abstract

<h3>Purpose</h3> The purpose of this study was to investigate the factors related to temporary mechanical support (tMCS) and surgical approach influencing post-LVAD outcomes in INTERMACS 1 patients. <h3>Methods</h3> We performed a retrospective review of all INTERMACS 1 patients implanted with the fully magnetically levitated LVAD in our institution from September 2015 through March 2021. Influence of the following factors on in-hospital survival were analyzed: type and time on tMCS; change in the tMCS level (<i>step-up:</i> IABP→ECMO and/or Impella, Impella→ ECMO±Impella; <i>step-down:</i> ECMO+Impella→ ECMO or Impella); heart failure acuity; and surgical approach. <h3>Results</h3> Of 287 implanted patients, 102 (35.5%) were INTERMACS profile 1 and included in the study. Full sternotomy (FS) was used in 25 (24.5%) patients and less invasive surgery (LIS) in 77 (75.5%) patients. Patients in the FS group were more frequently bridged with IABP in contrast to LIS patients supported with Impella. Postoperatively, LIS patients bled less, required shorter mechanical ventilation, and had a lower incidence of severe right ventricular failure. In-hospital survival was similar (Table 1). Multivariate analysis demonstrated a positive correlation between IABP and in-hospital survival while FS demonstrated a negative effect (Figure 1). <h3>Conclusion</h3> Patients presenting with cardiogenic shock should be expeditiously evaluated for LVAD therapy while supported with adequate tMCS tailored to the patient's requirements. Less invasive LVAD implantation may alleviate some of the perioperative risks. Future trials are required to confirm our data.