The Percutaneous Ventricular Assist Device in Severe Refractory Cardiogenic Shock

Objectives We evaluated the efficacy and safety of the percutaneous ventricular assist device (pVAD) in patients in severe refractory cardiogenic shock (SRCS) despite intra-aortic balloon pump (IABP) and/or high-dose vasopressor support. Background SRCS is associated with substantial mortality despite IABP counterpulsation. Until recently, there was no rapid, minimally invasive means of providing increased hemodynamic support in SRCS. Methods A total of 117 patients with SRCS implanted with TandemHeart pVAD (CardiacAssist, Inc., Pittsburgh, Pennsylvania) were studied, of whom 56 patients (47.9%) underwent active cardiopulmonary resuscitation immediately before or at the time of implantation. Data was collected regarding clinical characteristics, hemodynamics, and laboratory values. Results Eighty patients had ischemic and 37 patients had nonischemic cardiomyopathy. The average duration of support was 5.8 +/- 4.75 days. After implantation, the cardiac index improved from median 0.52 (interquartile range [IQR]: 0.8) l/(min center dot m(2)) to 3.0 (IQR: 0.9) l/(min center dot m(2)) (p < 0.001). The systolic blood pressure and mixed venous oxygen saturation increased from 75 (IQR: 15) mm Hg to 100 (IQR: 15) mm Hg (p < 0.001) and 49 (IQR: 11.5) to 69.3 (IQR: 10) (p < 0.001), respectively. The urine output increased from 70.7 (IQR: 70) ml/day to 1,200 (IQR: 1,620) ml/day (p < 0.001). The pulmonary capillary wedge pressure, lactic acid level, and creatinine level decreased, respectively, from 31.53 +/- 10.2 mm Hg to 17.29 +/- 10.82 mm Hg (p < 0.001), 24.5 (IQR: 74.25) mg/dl to 11 (IQR: 92) mg/dl (p < 0.001), and 1.5 (IQR: 0.95) mg/dl to 1.2 (IQR: 0.9) mg/dl (p = 0.009). The mortality rates at 30 days and 6 months were 40.2% and 45.3%, respectively. Conclusions The pVAD rapidly reversed the terminal hemodynamic compromise seen in patients with SRCS refractory to IABP and vasopressor support. (J Am Coll Cardiol 2011;57:688-96) (C) 2011 by the American College of Cardiology Foundation