Temporary Mechanical Circulatory Support Bridging Strategies And Post-operative Outcomes In Acute Decompensated Heart Failure-related Cardiogenic Shock Patients Undergoing Heart Transplantation Or Durable Left Ventricular Assist Device Implantation: A Society Of Thoracic Surgeons Database Analysis

Abstract

Introduction Temporary mechanical circulatory support (TMCS) bridging strategies are increasingly used for acute decompensated heart failure-related cardiogenic shock (ADHF-CS). However, the impact of bridging approach on post-operative outcomes in ADHF-CS patients who receive a durable left ventricular assist device (LVAD) or heart transplant (HT) is unknown. Methods Durable LVAD or HT recipients from July 1, 2014 to December 31, 2019 with pre-operative ADHF-CS were identified in the Society of Thoracic Surgeons Adult Cardiac Surgery Database and stratified by pre-operative TMCS strategy. Associations between TMCS strategies and post-operative outcomes were evaluated using propensity-score matching and adjustment for pre-selected covariates (pre-operative hemoglobin, platelets, albumin, bilirubin, international normalized ratio, creatinine, cardiopulmonary resuscitation, and operative status). Results A total of 8,777 ADHF-CS patients were bridged to LVAD (5,975; 68%) or HT (2,802; 32%). The composite of operative/30-day death following LVAD or HT was highest in patients managed with VA ECMO (22%) and lowest in those managed without TMCS (7%), with a stepwise gradient of incidence by level of hemodynamic support (Figure, top). Other post-operative outcomes including major bleeding, cerebrovascular accident, cardiac arrest, prolonged mechanical ventilation, renal failure, and sepsis/pneumonia followed a similar pattern. However, after propensity score matching and adjustment, there were no differences in the odds of operative/30-day death or major bleeding with IABP versus no TMCS (Figure, bottom). While there was no difference in operative/30-day death, odds of major bleeding were lower with catheter-based MCS compared with IABP (OR 0.70, 95% CI 0.53 - 0.92). Conclusion ADHF-CS patients experience high rates of cardiac and non-cardiac adverse events post- LVAD and HT. A crude relationship between TMCS bridging strategy and post-operative outcomes was observed. However, after adjustment, pre-operative TMCS bridging strategy did not independently confer risk of near-term post-operative mortality among ADHF-CS patients who underwent HT or durable LVAD implantation. Temporary mechanical circulatory support (TMCS) bridging strategies are increasingly used for acute decompensated heart failure-related cardiogenic shock (ADHF-CS). However, the impact of bridging approach on post-operative outcomes in ADHF-CS patients who receive a durable left ventricular assist device (LVAD) or heart transplant (HT) is unknown. Durable LVAD or HT recipients from July 1, 2014 to December 31, 2019 with pre-operative ADHF-CS were identified in the Society of Thoracic Surgeons Adult Cardiac Surgery Database and stratified by pre-operative TMCS strategy. Associations between TMCS strategies and post-operative outcomes were evaluated using propensity-score matching and adjustment for pre-selected covariates (pre-operative hemoglobin, platelets, albumin, bilirubin, international normalized ratio, creatinine, cardiopulmonary resuscitation, and operative status). A total of 8,777 ADHF-CS patients were bridged to LVAD (5,975; 68%) or HT (2,802; 32%). The composite of operative/30-day death following LVAD or HT was highest in patients managed with VA ECMO (22%) and lowest in those managed without TMCS (7%), with a stepwise gradient of incidence by level of hemodynamic support (Figure, top). Other post-operative outcomes including major bleeding, cerebrovascular accident, cardiac arrest, prolonged mechanical ventilation, renal failure, and sepsis/pneumonia followed a similar pattern. However, after propensity score matching and adjustment, there were no differences in the odds of operative/30-day death or major bleeding with IABP versus no TMCS (Figure, bottom). While there was no difference in operative/30-day death, odds of major bleeding were lower with catheter-based MCS compared with IABP (OR 0.70, 95% CI 0.53 - 0.92). ADHF-CS patients experience high rates of cardiac and non-cardiac adverse events post- LVAD and HT. A crude relationship between TMCS bridging strategy and post-operative outcomes was observed. However, after adjustment, pre-operative TMCS bridging strategy did not independently confer risk of near-term post-operative mortality among ADHF-CS patients who underwent HT or durable LVAD implantation.