Prognostic value of vasoactive-inotropic score following continuous flow left ventricular assist device implantation

doi:10.1016/j.healun.2019.05.007

The Journal of Heart and Lung Transplantation

Volume 38, Issue 9, September 2019, Pages 930-938

https://doi.org/10.1016/j.healun.2019.05.007 Get rights and content

BACKGROUND

The purpose of this study is to evaluate the utility of vasoactive-inotropic score (VIS) in predicting outcomes after left ventricular assist device (LVAD) implantation and explore possible mechanisms of post-operative hemodynamic instability.

METHODS

Retrospective review was performed in 418 consecutive patients with LVAD implantation. VIS was calculated as dopamine + dobutamine + 10 × milrinone + 100 × epinephrine + 100 × norepinephrine (all μg/kg/min) + 10000 × vasopressin (U/kg/min) after initial stabilization in the operating room and upon arrival at the intensive care unit. The primary outcome was in-hospital mortality. The secondary outcomes were a composite of in-hospital mortality, delayed right ventricular assist device (RVAD) implantation, and continuous renal replacement therapy. The pre-operative biomarkers of inflammation, oxidative stress, endotoxemia and gut-derived metabolite trimethylamine-N-oxide (TMAO) were measured in a subset of 61 patients.

RESULTS

Median VIS was 20.0 (interquartile range 13.3–27.9). VIS was an independent predictor of in-hospital mortality (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.03–1.09, p < 0.001) and composite outcome (OR 1.03, 95% CI 1.01–1.06, p = 0.008). In-hospital mortality increased for each VIS quartile (0% vs 3.9% vs 7.6% vs 12.3%, p = 0.002). VIS was superior to other established LVAD risk models as a predictor of in-hospital mortality (area under the curve 0.73, 95% CI 0.64–0.82). The optimal cut-off point for VIS as a predictor of in-hospital mortality was 20. Pre-operative hemoglobin level was the only independent predictor of VIS ≥ 20 (p = 0.003). Patients with a high VIS were more likely to have elevated TMAO pre-operatively (53.6% vs 25.8%, p = 0.03).

CONCLUSIONS

A high post-operative VIS is associated with adverse in-hospital outcomes and is a better predictor of in-hospital mortality compared with existing LVAD risk models. Whether early hemodynamic stabilization using RVAD may benefit patients with a high VIS remains to be investigated.

Section snippets

Study population

This study was approved by the Columbia University Irving Medical Center Institutional Review Board with a waiver of consent. A total of 469 adult (age ≥ 18) patients received LVAD implantation from April 2004 to December 2015 at Columbia University Irving Medical Center. Of those, 418 (89.1%) patients were included in this study after excluding 19 (4.1%) patients who received concomitant RVAD at the time of initial LVAD implantation and 32 (6.8%) patients with limited chart availability.

Calculation of VIS and hemodynamic data

VIS

VIS as a predictor of clinical outcomes

Pre- and intraoperative characteristics of all patients are outlined in Table 1. In the entire cohort, the mean age was 57.8 ± 13.1 years, 82.1% were male, 36.6% were undergoing destination therapy, and 40.4% had ischemic etiology. A total of 83.7% of patients were on inotrope support and 8.4% patients were on vasopressors pre-operatively. The median VIS was 20.0 (IQR 13.3–27.9). The maximum VIS score was 85.0, and the overall distribution is shown in the boxplot and histogram in Figure 1. VIS

Discussion

The purpose of this study was to evaluate the utility of post-operative VIS (a combined marker of inotrope and vasopressor requirement) to predict adverse outcomes when calculated after initial stabilization in the OR and upon arrival at the intensive care unit and to explore possible mechanisms for post-operative hemodynamic instability.

The findings show that VIS is an independent predictor and composite outcome of in-hospital mortality, delayed RVAD implantation and RRT, and the optimal

Disclosure statement

Y.N. received consulting fees from Abbott Laboratories/St Jude Medical. The remaining authors have no conflicts of interest to disclose.

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HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support
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The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacological therapies administered in the preoperative, intraoperative, postoperative, and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials, and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable mechanical circulatory support, focusing on pharmacological therapies administered to patients on continuous flow LVADs. Although quality data in the LVAD population are few, the use of guideline-directed heart failure medical therapies and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacological regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications, are addressed. Finally, this document touches on important potential pharmacological interactions from antidepressants and herbal and nutritional supplements of relevance to providers of patients on LVAD support.
Online Hemodiafiltration Compared to Conventional Hemodialysis in Critically Ill Patients
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Before each IRRT treatment performed in the ICU, we collected information about baseline arterial blood pressure, vasopressor support, and use of mechanical ventilation, as well as the following laboratory parameters: lymphocyte count, neutrophil count, and monocyte count. Vasopressor support was quantified using the vasoactive-inotropic score defined as [vasoactive-inotropic score = dopamine dose + dobutamine dose + 100 × epinephrine dose + 10 × milrinone dose + 10,000 × vasopressin dose + 100 × norepinephrine dose] where all doses are in μg/kg/min except vasopressin dose which is in U/kg/min.21-24 For each IRRT treatment in the ICU, we collected information about the minimal arterial blood pressure and maximal vasoactive support reached during the treatment.
Online hemodiafiltration (HDF) has been increasingly used for improved clearance of middle molecular weight toxins. The impact of this mode of clearance is unknown in critically ill patients. We aimed to determine whether the use of HDF in acute kidney injury (AKI) is associated with lower mortality and improved kidney recovery up to 90 days after initiation of therapy.
Single-center retrospective cohort study using data from 2017 to 2020 of adults with AKI who initiated intermittent renal replacement therapy (IRRT) in the intensive care unit (ICU), using either hemodialysis (HD) or HDF depending on the maintenance status of the water system without regards for patient characteristics. We assessed association with patient-events and session-events using time-dependent Cox models and general estimating equations models, respectively.
We included 182 adults with AKI for whom 848 IRRT sessions were performed in the ICU. The 90-day mortality rate was 43 of 182 (24.6%). There was no significant association with the use of HDF and mortality (adjusted hazard ratio [aHR]: 0.85 (0.43; 1.67) P = 0.64), kidney recovery (aHR: 1.18 (0.76; 1.84) P = 0.47), or intradialytic hypotension (adjusted odds ratio [aOR]: 0.91 confidence interval [CI]: 0.64–1.28 P = 0.58). HDF treatment was associated with a lower rate of subsequent vasopressor use (aOR: 0.60 CI: 0.36–0.99 P = 0.047) and a greater reduction of the neutrophil-to-lymphocyte ratio (NLR) following the first session (−15.0% vs. +5.1%, P = 0.047) but was also associated with increased risk of filter thrombosis during treatment (aOR: 2.42 CI: 1.67–3.50 P < 0.001).
The use of HDF in the setting of AKI was not associated with a differential risk of mortality or kidney recovery.
Relation of Left Ventricular Assist Device Infections With Cardiac Transplant Outcomes
2021, American Journal of Cardiology
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Although vasoplegia occurred more frequently in patients with LSI, the difference was not statistically significant. This finding was further validated by the absence of difference in the calculated VIS, which has been increasingly used to calculate hemodynamic cardiopulmonary derangements after cardiac surgery.21–24 The presence of LSI did not affect the rate of perioperative renal failure or ICU or hospital length of stay, and it did not influence the rate of allograft rejection or mortality within 1 year of HT.
Left ventricular assist device (LVAD)–specific infections (LSIs) are common in patients on LVAD support awaiting heart transplant (HT), yet their impact on post-HT outcomes is not completely understood. We hypothesized that LSIs would result in vasoplegia and negatively affect post-HT 30-day and 1-year outcomes. LSI was defined as driveline, pump, or pocket infection. The short-term outcome was a composite of acute renal failure, allograft rejection, and mortality at 30 days after HT. The long-term outcome was a composite of allograft rejection and death within 1 year after HT. We performed a retrospective analysis of 111 HT recipients bridged with durable LVAD support at our institution from May 2012 to August 2019. Of these, 63 patients had LSIs, with 94% of the infections being driveline infections. Vasoplegia was more prevalent in the LSI group but not significantly (7 vs 2 persons, p = 0.3). There was no difference in the composite end point of acute renal failure, rejection, or death at 30 days (30% vs 25%, p = 0.55) or 1-year end point of rejection and death (38% vs 40%, p = 0.87) in patients with LSI versus those without LSI. In conclusion, LSIs were common in patients on LVAD who underwent HT in our single-center contemporary cohort. However, LSI was not associated with adverse outcomes at 30 days or at 1 year after HT.
Association Between Timing of Extracorporeal Membrane Oxygenation and Clinical Outcomes in Refractory Cardiogenic Shock
2021, JACC: Cardiovascular Interventions
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Hemodynamic, laboratory, and echocardiographic parameters were measured prior to ECMO implantation. Required doses of inotropes and/or vasopressors were ascertained for each patient and transformed into a vasoactive inotropic score for standardization purposes (18–20). Severity of CS was classified according to the Society for Cardiovascular Angiography and Interventions classification system (21).
The aim of this study was to investigate whether earlier extracorporeal membrane oxygenation (ECMO) support is associated with improved clinical outcomes in patients with refractory cardiogenic shock (CS).
The prognosis of patients with refractory CS receiving ECMO remains poor. However, little is known about the association between the timing of ECMO implantation and clinical outcomes in these patients.
From a multicenter registry, 362 patients with refractory CS who underwent ECMO between January 2014 and December 2018 were identified. Participants were classified into 3 groups according to tertiles of shock-to-ECMO time (early, intermediate, and late ECMO). Inverse probability of treatment weighting was conducted to adjust for baseline differences among the groups, followed by a weighted Cox proportional hazards regression analysis to calculate hazard ratios and 95% confidence intervals for 30-day mortality associated with each ECMO time group.
The overall 30-day mortality rate was 40.9%. The risk for 30-day mortality was lower in the early group than in the late group (hazard ratio: 0.53; 95% confidence interval: 0.28 to 0.99). Early ECMO support was also associated with lower risk for in-hospital mortality, ECMO weaning failure, composite of all-cause mortality or rehospitalization for heart failure at 1 year, all-cause mortality at 1 year, and poor neurological outcome at discharge. However, the incidence of adverse events, including stroke, limb ischemia, ECMO-site bleeding, and gastrointestinal bleeding, did not differ significantly among the groups.
Earlier ECMO support was associated with improved clinical outcomes in patients with refractory CS.
The association of vasoactive-inotropic score and surgical patients’ outcomes: a systematic review and meta-analysis
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Prognostic implication of Vasoactive Inotropic Score in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation
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ORIGINAL CLINICAL SCIENCEPrognostic value of vasoactive-inotropic score following continuous flow left ventricular assist device implantation

BACKGROUND

METHODS

RESULTS

CONCLUSIONS

Section snippets

Study population

Calculation of VIS and hemodynamic data

VIS as a predictor of clinical outcomes

Discussion

Disclosure statement

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Card Fail

J Card Fail

J Card Fail

J Am Coll Cardiol

J Heart Lung Transplant

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Mol Cell Cardiol

Am J Cardiol

J Am Coll Cardiol

Advanced heart failure treated with continuous-flow left ventricular assist device

N Engl J Med

Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004-2011

Open Heart

Use of a continuous-flow device in patients awaiting heart transplantation

N Engl J Med

Low accuracy of the HeartMate Risk Score for Predicting Mortality Using the INTERMACS Registry Data

ASAIO J

Circulating microbial RNA and health

Sci Rep

ORIGINAL CLINICAL SCIENCE
Prognostic value of vasoactive-inotropic score following continuous flow left ventricular assist device implantation