Poor outcomes resulting from ventricular assist devices implanted in hospitals without dedicated ventricular assist device programs

摘要

Background: There is increasing drive for early implantation of ventricular assist devices (VADs) for patients in cardiogenic shock. Implants in non-VAD centers are often performed by teams without specific expertise in VAD therapy. We review the outcomes of patients transferred to a quaternary VAD center after VAD implants in outside hospitals.Methods: Retrospective review of 12 patients transferred to our center with VADs implanted in non-VAD centers. Indication for VAD was acute shock (6) and post-cardiotomy shock (6). Median interval from implant to transfer was 3.5 days (range 1–9).Results: Organ dysfunction was evident in most patients on transfer (medians: creatinine 2 mg/dl, bilirubin 2.6 mg/dl, AST 193 U/l). There were complications directly related to device placement in 9/12 patients resulting in air embolism–one, massive hemorrhage–two, inadequate device function–four, ventricular fibrillation–one, wound necrosis–three, and hypoxia from shunting–one. Ten patients died in intensive care a median of 6 days post-transfer (range 2–35). One died in the hospital on day 143, while one was discharged from the hospital after 139 days.Conclusions: We observed a high frequency of technical problems related to VAD implantation, almost invariably early mortality, and a very high level of resource use in patients transferred to our center after VAD placement at outside hospitals. The increasingly popular ‘hub and spoke’ approach to VAD therapy may not necessarily be the optimal strategy for managing cardiogenic shock in the community, especially as it leaves some patients with a suboptimal starting point due to surgically related issues.