Similar transplantation outcomes in patients bridged with cardiac assist
devices for acute cardiogenic shock versus chronic heart failure
Stavros G. Drakosa,b, Abdallah G. Kfourya,⁎, James W. Longa, James C. Stringhamb,c,
Edward M. Gilbertb,c, Benjamin D. Hornea, Mary-Beth E. Haganc,
Karah Nelsona, Dale G. Renlunda,b
aUtah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program, LDS Hospital, Salt Lake City, Utah, United States
bUniversity of Utah School of Medicine, Salt Lake City, Utah, United States
cGeorge E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, United States
Received 5 December 2006; received in revised form 12 March 2007; accepted 1 May 2007
Available online 18 June 2007
Background: Heart failure (HF) patients may require cardiac assist device implantation prior to transplantation (Tx) because of either acute
cardiogenic shock (ACS), with no prior history of HF, or for progression of pump failure in the setting of chronic HF.
Aims: To investigate whether patients implanted with a cardiac assist device for ACS, have similar post-Tx outcomes as those who underwent
cardiac assist device implantation because of progressive chronic HF.
Methods and results: We compared post-Tx outcomes of consecutive patients bridged due to ACS (Acute Group) with the outcomes of
patients bridged due to deterioration of chronic HF (Chronic Group). Seventy-three patients had a cardiac assist device implanted and
underwent subsequent cardiac Tx. Thirty-five patients (48%) had a cardiac assist device implanted due to ACS, most often caused by massive
acute myocardial infarction, and 38 patients (52%) because of progressive chronic HF. Despite greater compromise at the time of
implantation, the Acute Group recovered satisfactorily and underwent Tx with similar post-Tx survival rates as the Chronic Group patients
[1-year survival: 88.6% vs 86.8%, p=0.80, actuarial survival (mean follow-up 4.2 years): 80.0% vs 81.6%, p=0.86)]. Furthermore, no
significant differences were observed between the 2 groups in various post-Tx events.
Conclusion: Patients with ACS who underwent emergency cardiac assist device implantation as bridge to Tx had similar post-Tx outcomes
as their more chronically ill counterparts who underwent device implantation on a non-urgent basis.
© 2007 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
Keywords: Chronic heart failure; Acute cardiogenic shock; Cardiac assist devices; Heart transplantation
The advent of mechanical assistance for the failing
myocardium has been life saving for chronic heart failure
patients awaiting heart transplantation [1–3]. However, many
patients without prior history of chronic heart failure undergo
implantation of a cardiac assist device on an emergency basis
due torefractory acute cardiogenic shock (ACS) asa bridge to
either recoveryor transplantation [4–9]. In the case of elective
implementation of long-term mechanical circulatory support
(MCS) asbridgetotransplantthe chronic heart failure patients
undergo a comprehensive evaluation to assess the need for
transplant as well as to identify significant comorbidities that
could shorten post-transplant survival [10–12]. In contrast,
ACS patients' critical condition does not permit thorough
European Journal of Heart Failure 9 (2007) 845–849
⁎Corresponding author. Division of Cardiology, LDS Hospital, 8th
Avenue andC Street, Salt Lake City, Utah 84143,United States. Tel.: +1 801
E-mail address: firstname.lastname@example.org (A.G. Kfoury).
1388-9842/$ - see front matter © 2007 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
by guest on June 9, 2013
. Whether undetected problems due to the brevity of these
emergency evaluations negatively impacts outcomes after
cardiac transplantation compared with those candidates with
non-urgent evaluations is unknown.
We have previously reported similar post-transplant
outcomes of patients bridged to transplantation with MCS
compared to their non-MCS counterparts . In this report,
with almost the same MCS patient population as in our
previous report, we sought to investigate whether patients
with no prior history of heart failure who require emergency
cardiac assist device implantation as a bridge to transplant
because of ACS, have similar post-transplant outcomes as
those who underwent non-urgent device implantation
because of progressive chronic heart failure.
We retrospectively compared post-transplantation out-
comes of two groups of patients who were bridged to heart
used totreat patientssuffering from ACS refractory tooptimal
conventional treatment (Acute Group). ACS was diagnosed
when the following criteria were fulfilled: systemic hypoten-
sion (a systolic blood pressure of b90 mm Hg), end-organ
a cardiac index of no more than 2.2 L/min/m2of body-surface
area and a pulmonary–capillary wedge pressure of at least
heart failure patients who had MCS deployed due to clinical
and haemodynamic deterioration while waiting for heart
Ventricular Assist System (Thoratec, Pleasanton, CA) and the
CardioWest Total Artificial Heart (SynCardia Systems Inc,
Tucson, AR) were the devices utilized.
Various short-term (b1 month) and long-term (2–
12 months) post-transplantation outcomes were compared
between the 2 groups. Infection was defined as fever N38.1C,
elevated white blood cells and positive cultures of blood or
other fluid, requiring intravenous antimicrobial treatment.
Rejection was defined as International Society for Heart and
Lung Transplantation (ISHLT) grade ≥3A and haemodyna-
mically significant rejectionwas defined asrejection requiring
serum creatinine N3 mg/dl and acute hepatic dysfunction was
defined as liver function tests elevated more than 3 times
normal. Chronic renal insufficiency was defined as a serum
creatinine measuring consistently N2 mg/dl which persisted
for 6 months or more. Allograft dysfunction was defined as
acute cardiac allograft dysfunction requiring intraaortic
balloon counterpulsation or other temporary mechanical
support. Thoracic complications included pericardial tampo-
nade (requiring pericardiocentesis), adult respiratory distress
syndrome, pneumothorax, haemothorax, and pleural effusion
requiring thoracentesis. Thromboembolic complications in-
cluded pulmonary embolism and deep vein thrombosis. Cen-
tral nervous system complications included stroke and anoxic
brain damage. Atrial dysrhythmias included atrial fibrillation,
atrial flutter, and permanent pacemaker implantation. Gas-
trointestinal complications included ileus, pancreatitis, oeso-
phageal perforation and dysphagia. Neurologic complications
included peripheral neuropathy, leg cramps and restless leg
syndrome. Allograft coronary artery disease was defined as
stenosis N50% of at least one coronary artery. The
investigation conforms with the principles outlined in the
Declaration of Helsinki and our institutional committee on
human research has approved the study protocol.
2.1. Statistical methods
Comparisons of demographic or clinical factors between
the two groups of patients were analysed with the X2and
Student's t-test. Kaplan–Meier survival estimates were
compared with the long-rank test. Cox regression was used
to compute the survival function for acute vs. chronic with
adjustment for significant and confounding covariables.
Survival and event-free (re-transplantation, ISHLT 3A or
worse rejection, or haemodynamically significant rejection)
survival were evaluated. Due to the relatively small number
of individuals in the study, all regression models were built
with forced entry of only 4–6 variables simultaneously, with
the final models including only 3 variables. Various
demographic, pre-implantation, and post-implantation vari-
ables were considered as potential predictors in regression
modelling (age, gender, type of device, history of diabetes
mellitus or peripheral vascular disease, pulmonary function
tests, ischaemic time, donor age, donor positive CMV,
recipient positive CMV, proportion of male donors, body
surface area, duration of mechanical support, New York
Heart Association functional class at implant, heart rate at
implant, filling pressures and cardiac output at implant, left
ventricular ejection fraction at implant, laboratory values at
implant as creatinine, blood urea nitrogen, sodium, bilirubin,
utilization at implant, panel reactive antibody at transplant).
A p-value less than 0.05 was considered significant.
We retrospectively reviewed 279 patients who underwent
cardiac transplantation from 1993 to 2002. In this study we
are reporting only the outcomes of patients who required pre
transplant MCS and were finally successfully bridged to
heart transplantation (n=73). In thirty-five (48%) of these
patients MCS was implemented due to ACS (Acute Group)
and in the remaining 38 (52%) patients due to deterioration
of chronic heart failure (Chronic Group).
Heart failure aetiology is described in Table 1 and baseline
patient characteristics are described in Table 2. The Acute
time of implantation than the Chronic Group, as manifest by
the higher need for various intravenous inotropic and
vasoactive agents and more frequent use of intraaortic balloon
846 S.G. Drakos et al. / European Journal of Heart Failure 9 (2007) 845–849
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counterpulsation (Table 2). Notably, at implantation time one
severe acute renal failure requiring temporary dialysis as
opposed to only two patients in the Chronic group.
the two groups in various post-transplant outcomes such as
duration of intensive care unit stay, extubation time and the
post-operative renal and hepatic function. The Acute Group
tended to receive more transfusions after transplantation.
Short term post-transplantation complications (b1 month)
such as acute renal and hepatic dysfunction, graft dysfunc-
tion, reoperation rates, infections, atrial dysrhythmias,
thoracic, thromboembolic, central nervous system and
gastrointestinal complications were found to be similar
between the two groups. However, regarding long-term post-
transplant complications (2–12 months) the Chronic group
tended to have an increased incidence of infections (23.7%
vs 5.7%, p=0.07) whereas other complication such as
chronic renal insufficiency, allograft coronary artery disease,
atrial dysrhythmias, thromboembolic, thoracic, gastrointes-
tinal and neurologic complications were comparable be-
tween the two groups.
Furthermore, no differences were seen in 1-year post-
transplantation survival (Fig. 1) and actuarial post-trans-
plantation survival (mean follow-up 4.2 years, Fig. 2). A
combined endpoint using death, re-transplantation, ISHLT
3A or worse rejection, or haemodynamically significant
rejection was evaluated. As seen in Fig. 3, the Acute group
did not differ from the Chronic group.
In multivariable analyses, survival tended to be predicted
by gender (improved survival for males) and higher left
ventricular ejection fraction at implant, but not by MCS
aetiology, i.e. Acute vs. Chronic (hazard ratio=1.08, p=0.89
for Acute). Furthermore, multivariable analyses revealed that
event-free survival was not found to be predicted by MCS
aetiology (hazard ratio=1.04, p=0.89).
Bridging to transplantation with long-term MCS has been
life saving for many patients with end-stage chronic heart
the implementation of chronic MCS as bridge to transplant in
end-stage heart failure patients was associated with post-
transplant outcomes similar or even better compared to the
outcomes of patients that were transplanted without requiring
such a bridge. Furthermore, quite often acutely ill patients
suffering from ACS refractory to optimal conventional
treatment require implementation of MCS [4–9,18–26]. In
these patients suffering from various causes of ACS, such as
acute myocardial infarction, post-cardiotomy failure, acute
myocarditis etc, the probability of myocardial recovery to the
point the cardiac assist device can safely be withdrawn is
highly unpredictable [4–7]. Sometimes a short-term assist
deviceservesasbridgetoother therapeutic managementandit
high risk re-operations for substitution of a short-term with a
long-term cardiac assist device (bridge to bridge) .
Type of device
HeartMate IP or VE
History of DM (%)
Ischaemic time (minutes)
Donor age (years)
Donor positive CMV (%)
Male Donors (%)
Duration of mechanical support
CMV positive recipient (%)
Tx PRA (%)
At implantation time
Implant NYHA class
Implant heart rate
Implant Syst.BP (mmHg)
Impant Syst. PA (mmHg)
Implant PCWP (mmHg)
Implant CO (L/min)
Implant PVR (WU)
Implant left ventricular
ejection fraction (%)
Implant bilirubin (mg/dl)
Implant sodium (mmol/L)
Implant BUN (mg/dl)
Implant haemoglobin (g/dl)
IABP utilization (%)
CPS/ECMO utilization (%)
Short-term LVAD (%)
(bridge to bridge)
BP: Blood pressure, BSA: Body surface area, BUN: Blood urea nitrogen,
CAD: Coronary artery disease, CO: Cardiac output, CPS/ECMO:
percutaneous cardiopulmonary support systems/ extracorporeal membrane
oxygenation, DM: Diabetes mellitus, IABP: Intraaortic balloon pump
counterpulsation, LVAD: left ventricular assist device, NYHA: New York
Heart Association, PA: Pulmonary artery pressure, PCWP: Pulmonary
capillary wedge pressure, PRA: Panel Reactive Antibody, PVR: Pulmonary
vascular resistance, TAH: Total artificial heart, Tx: Transplantation.
Heart failure aetiology
1. Acute group (n=35)
Acute myocardial infarction
Post cardiotomy cardiogenic shock
2. Chronic group (n=38)
Ischaemic cardiomyopathy (%)
Idiopathic dilated cardiomyopathy (%)
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Taking all these in account, an emerging therapeutic
strategy, that has to be validated, is the direct implementation
of long-term cardiac assist devices, approved to be used as
ACS [9,13,27–29]. One of the problems with this therapeutic
strategy is that it is almost impossible to have these marginal
patients undergo thorough pre-transplant evaluations to assess
their transplant candidacy eligibility [13,28]. Even in the case
that this could be done it is not always easy to predict in
advance whether a profound cardiogenic shock patient whose
vital organs are being fully supported both medically and
mechanically would finally recover to the point he can safely
undergo a heart transplantation .
In our study, we found that the ACS patients that survived
to transplantation after implantation of a long-term cardiac
assist device had similar post-transplant outcomes as their
more chronically ill counterparts. As a limitation of this
study could be considered the fact we do not provide any
data on the post-implantation outcomes of all ACS patients
that required cardiac assist device implantation in our
program but only data for the proportion of these patients
that finally survived to transplantation. On the other hand
though, the issue we really intended to address in this study
was not the effectiveness of cardiac assist devices in treating
refractory ACS. Regardless of the short-term outcome of
such a therapeutic approach, what we really wanted to focus
on is whether the proportion of ACS patients that survives
after requiring to be mechanically assisted can subsequently
be safely transplanted with acceptable post-transplant out-
comes. Our data show that once resuscitated from such acute
catastrophic situations these critically ill patients can
subsequently be transplanted with morbidity and mortality
rates similar to those of their more chronically ill counter-
parts that also required to be mechanically bridged.
Fig. 2. Post-transplantation actuarial survival. MCS: Mechanical circulatory
Acute Chronicp value
Hospital stay (days)
ICU stay (days)
Extubation time (hours)
Peak Creat (mg/dl)
Peak BUN (mg/dl)
Peak AST (mg/dl)
Peak ALT (mg/dl)
Peak Total Bilirubin (mg/dl)
ALT: amino alanine transferase, AST: aspartate amino transferase, BUN:
Blood Urea Nitrogen, FFP: Fresh frozen plasma, ICU: Intensive care unit,
PLT: Platelets, pRBC: packed red blood cells.
Peak Creatinine, BUN, AST, ALT, Total Bilirubin: peak values that these
variables reached perioperatively.
Fig. 1. Post-transplantation 1-year survival. MCS: Mechanical circulatory
Fig. 3. Freedom from combined end-point (death or re-transplantation or
rejection or haemodynamically significant rejection). MCS: Mechanical
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Nevertheless, the above mentioned issue of the effective- Download full-text
ness of MCS in the setting of refractory ACS and the post-
operative outcomes of this therapeutic approach, an issue that
we have not addressed in our study, is of great importance and
the Columbia–Presbyterian group , of the 115 patients
who required left ventricular assist device support, 73 (63%)
patients required emergency placement due to acute cardio-
genic shock; 70% of these patients survived to transplant
compared with 83% of those with non-urgent device
implantation (not statistically significant). Furthermore, in
accordance to our study, in that report the post-transplant
survival outcome was similar for patients with emergency
device placement and those with non-urgent placement .
the modest sample size of the patient cohort, so a survival
difference might have been missed owing to insufficient
and long-term post transplant morbidity variables, such as if
one of these variables was found tobe significantly different it
could then suggest the probability of adverse outcomes in
terms of survival in a larger patient cohort or a longer follow-
up. Nevertheless, no significant difference was identified
between the two groups in any of the studied variables.
In conclusion, in our study patients with acute cardio-
genic shock bridged to transplantation with cardiac assist
device had similar post-transplant outcomes as their more
chronically ill counterparts. Therefore, the timely application
of long-term mechanical circulatory support for acute
catastrophic situations appears warranted despite the abbre-
viated transplant evaluations and should be investigated
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