Differential indication for mechanical circulatory support following heart transplantation

Purpose: We describe our experience with ventricular assist devices (VAD) in patients with cardiogenic shock refractory to pharmacological therapy and support using intraaortic balloon pump after cardiac transplantation. Patients: Between July 1987 and August 1997, 848 patients underwent cardiac transplantation in our hospital. Interventions: Fifteen patients (1.8%) needed mechanical circulatory support for refractory cardiac failure due to right heart failure (six patients), primary graft failure (three patients), and acute rejection (six patients). Three pump systems were used: Biomedicus Centrifugal Pump, Abiomed BVS 500, and Thoratec VAD. The choice of system depended on the indication and quality of each device. Seven patients (47%) could be weaned from the mechanical circulatory support (MCS) system and three patients (20%) are long-term survivors. Results: All 15 patients developed at least one serious complication, such as multiorgan failure (MOF), liver failure, acute renal failure or sepsis. Twenty-five per cent had severe bleeding and 13% had neurological complication. Mortality was due mostly to MOF, MOF and sepsis or sepsis. The survivors had a CI greater than 2.2 l·min·m2, total bilirubin less than 1.0 U/1, and did not undergo resuscitation. Conclusions: Heart failure after cardiac transplantation severe enough to require MCS is currently associated with several major complications and high mortality (80%).