Abstract
Left ventricular assist devices (LVADs) have become the standard of care for patients with end-stage heart failure as a bridge-to-transplant (BTT) therapy [1] and as a destination therapy (DT) [2]. Over the past decade, numbers of LVAD implants in North America have grown exponentially, with over 15,000 patients undergoing LVAD implantation with continuous-flow LVAD. Approval of DT and other studies have accelerated the shift of timing of LVAD implantation to more ambulatory patients with heart failure in several years [3]. However, in the seventh annual Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) report, about 15% of all patients with INTERMACS profile 1 underwent LVAD implantation, and this rate has not changed in the past several years [4]. Therefore, it is important to discuss about the treatment strategy for patients at the INTERMACS level 1. The major problems of patients at the INTERMACS level 1 include not only decompensated hemodynamic condition but also other organ dysfunction or uncertified neurological status. At the first encounter for patients with cardiogenic shock, candidacy for DT or BTT LVAD is often unclear. In addition, because of the severity of their illness, the time to make a decision is very limited. Therefore, an alternative approach instead of primary implantable LVAD insertion may be considered using short-term mechanical circulatory support (MCS) for patients at the INTERMACS level 1. This treatment strategy is considered as a bridge-to-decision therapy. The merit of this strategy is that stabilization of hemodynamics and improvement of organ function can be achieved before long-term durable LVAD implantation. We reported favorable outcomes with CentriMag (Thoratec Co., Pleasanton, CA) VAD usage in patients with cardiogenic shock [5]. Moreover, recent advances in technology enable us to implant percutaneous short-term VADs such as extracorporeal membrane oxygenation (ECMO) and Impella (Abiomed, Danvers, MA). Percutaneous MCS devices can be less invasively implanted and are especially applicable for salvage treatment in critically ill cases [6]. This staged procedure has potential benefits to restore hemodynamic instability and end-organ function and may improve outcomes following definitive surgeries [7]. On the other hand, there remain several concerns in the bridge-to-decision strategy. Patients require a second intervention in cases which require subsequent implantable LVAD insertion. The second surgery after surgical short-term VAD requires adhesive dissection and more transfusions. Moreover, bridge-to-bridge surgery imposes increasing risk of device infection on patients [8]. In addition, bridging strategy using multiple MCS devices could increase medical cost and impose prolonged hospital stay. Thus, one-stage durable LVAD implantation is possibly advantageous with regards to cost and adverse consequences associated by multiple interventions. No studies have been conducted comparing outcomes between two strategies in INTERMACS 1 patients. Nonetheless, utmost careful attention must be paid for appropriate patient selection.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Miller LW, Pagani FD, Russell SD, John R, Boyle AJ, Aaronson KD et al (2007) Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 357:885–896
Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W et al (2001) Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 345:1435–1443
Estep JD, Starling RC, Horstmanshof DA, Milano CA, Selzman CH, Shah KB et al (2015) Risk assessment and comparative effectiveness of left ventricular assist device and medical management in ambulatory heart failure patients: results from the ROADMAP study. J Am Coll Cardiol 66:1747–1761
Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume ED et al (2015) Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transp 34:1495–1504
Takayama H, Soni L, Kalesan B, Truby LK, Ota T, Cedola S et al (2014) Bridge-to-decision therapy with a continuous-flow external ventricular assist device in refractory cardiogenic shock of various causes. Circ Heart Fail 7:799–806
Truby L, Mundy L, Kalesan B, Kirtane A, Colombo PC, Takeda K et al (2015) Contemporary outcomes of venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock at a large tertiary care center. ASAIO J 61:403–409
Takayama H, Soni L, Kalesan B, Truby LK, Ota T, Cedola S et al (2014) Bridge-to-decision therapy with a continuous-flow external ventricular assist device in refractory cardiogenic shock of various causes. Circ Heart Fail. 7:799–806
Yoshioka D, Sakaguchi T, Saito S, Miyagawa S, Nishi H, Yoshikawa Y et al (2012) Initial experience of conversion of Toyobo paracorporeal left ventricular assist device to DuraHeart left ventricular assist device. Circ J 76:372–376
McCarthy RE 3rd, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM et al (2000) Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med 342:690–695
Diddle JW, Almodovar MC, Rajagopal SK, Rycus PT, Thiagarajan RR (2015) Extracorporeal membrane oxygenation for the support of adults with acute myocarditis. Crit Care Med 43:1016–1025
Lorusso R, Centofanti P, Gelsomino S, Barili F, Di Mauro M, Orlando P et al (2015) Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: a 5-year multi-institutional experience. Ann Thorac Surg 27:S0003–S4975. (15)01375-2
Mody KP, Takayama H, Landes E, Yuzefpolskaya M, Colombo PC, Naka Y et al (2014) Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res 7:156–164
Pawale A, Pinney S, Ashley K, Flynn R, Milla F, Anyanwu AC (2013) Implantable left ventricular assist devices as initial therapy for refractory postmyocardial infarction cardiogenic shock. Eur J Cardiothorac Surg 44:213–216
Dang NC, Topkara VK, Leacche M, John R, Byrne JG, Naka Y (2005) Left ventricular assist device implantation after acute anterior wall myocardial infarction and cardiogenic shock: a two-center study. J Thorac Cardiovasc Surg 130:693–698
Yoshioka D, Sakaguchi T, Saito S, Miyagawa S, Nishi H, Yoshikawa Y et al (2012) Predictor of early mortality for severe heart failure patients with left ventricular assist device implantation: significance of INTERMACS level and renal function. Circ J 76:1631–1638
Klotz S, Vahlhaus C, Riehl C, Reitz C, Sindermann JR, Scheld HH (2010) Pre-operative prediction of post-VAD implant mortality using easily accessible clinical parameters. J Heart Lung Transplant. 29(1):45–52
Lietz K, Long JW, Kfoury AG, Slaughter MS, Silver MA, Milano CA et al (2007) Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: implications for patient selection. Circulation 116:497–505
Sandner SE, Zimpfer D, Zrunek P, Rajek A, Schima H, Dunkler D, Grimm M, Wolner E, Wieselthaler GM (2009) Renal function and outcome after continuous flow left ventricular assist device implantation. Ann Thorac Surg 87:1072–1078
Butler J, Geisberg C, Howser R, Portner PM, Rogers JG, Deng MC et al (2006) Relationship between renal function and left ventricular assist device use. Ann Thorac Surg 81:1745–1751
Leidenfrost J, Prasad S, Itoh A, Lawrance CP, Bell JM, Silvestry SC (2016) Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement. Eur J Cardiothorac Surg 49:73–77
Cowger J, Sundareswaran K, Rogers JG, Park SJ, Pagani FD, Bhat G et al (2013) Predicting survival in patients receiving continuous flow left ventricular assist devices: the HeartMate II risk score. J Am Coll Cardiol 61(3):313–321
Adamo L, Nassif M, Tibrewala A, Novak E, Vader J, Silvestry SC et al (2015) The heartmate risk score predicts morbidity and mortality in unselected left ventricular assist device recipients and risk stratifies INTERMACS class 1 patients. JACC Heart Fail 3:283–290
Saito S, Matsumiya G, Sakaguchi T, Miyagawa S, Yoshikawa Y, Yamauchi T et al (2010) Risk factor analysis of long-term support with left ventricular assist system. Circ J 74:715–722
Kormos RL, Teuteberg JJ, Pagani FD, Russell SD, John R, Miller LW et al (2010) Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg 139:1316–1324
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 Springer International Publishing Switzerland
About this chapter
Cite this chapter
Yoshioka, D., Takeda, K., Takayama, H., Naka, Y. (2017). Low INTERMACS Profiles: One-Stage Durable LVAD Implantation for INTERMACS Level 1: Indications and Contraindications. In: Montalto, A., Loforte, A., Musumeci, F., Krabatsch, T., Slaughter, M. (eds) Mechanical Circulatory Support in End-Stage Heart Failure. Springer, Cham. https://doi.org/10.1007/978-3-319-43383-7_10
Download citation
DOI: https://doi.org/10.1007/978-3-319-43383-7_10
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-43381-3
Online ISBN: 978-3-319-43383-7
eBook Packages: MedicineMedicine (R0)