The use of extracorporeal membrane oxygenation in patients with therapy refractory cardiogenic shock as a bridge to implantable left ventricular assist device and perioperative right heart support

Abstract

Implantation of left ventricular assist device (LVAD) as a bridge to recovery or transplantation is a widely accepted treatment modality. Preexisting organ dysfunction is thought to unfavorably affect patient survival after implantation of a ventricular assist device (VAD). We present our experience using extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock to stabilized organ function prior to LVAD implantation. Between September 2006 and March 2008, five patients in cardiogenic shock with preexisting organ dysfunction (impaired liver and kidney function) were supported with ECMO before LVAD implantation. ECMO-LVAD interval was 8 +/- 4 days. All patients were transferred to a LVAD. At the LVAD implantation time, glutamic-oxaloacetic transaminase (GOT) decreased from 206.25 +/- 106.93 Ul (-1) to 70.6 +/- 32.9 U l(-1), glutamic-pyruvic transaminase (GPT) decreased from 333.5 +/- 207.3 U l(-1) to 77.8 +/- 39.7 U l(-1), and creatinine decreased from 2.2 +/- 0.9 mg dl(-1) to 1.2 +/- 0.2 mg dl(-1). One patient died while on LVAD support due to not device related sepsis. One patient received successful heart transplantation. Overall survival was 80%. In all patients, we removed the ECMO 3 days after LVAD implantation. After removal of the ECMO there was no right heart failure. ECMO support can immediately stabilize circulation and provide organ perfusion in patients with cardiogenic shock. After improvement of organ function, LVAD implantation can be performed successfully in this patient collective. To avoid right ventricular failure, the ECMO should not be removed at the time of LVAD implantation, and used as a right ventricular support for the immediate postoperative period.