Evaluation of the preoperative vasoactive-inotropic score as a predictor of postoperative outcomes in patients undergoing heart transplantation

The association of vasoactive-inotropic score and surgical patients' outcomes: a systematic review and meta-analysis

BACKGROUND

The objective of this study is to conduct a systematic review and meta-analysis examining the relationship between the vasoactive-inotropic score (VIS) and patient outcomes in surgical settings.

METHODS

Two independent reviewers searched PubMed, Web of Science, EMBASE, Scopus, Cochrane Library, Google Scholar, and CNKI databases from November 2010, when the VIS was first published, to December 2022. Additional studies were identified through hand-searching the reference lists of included studies. Eligible studies were those published in English that evaluated the association between the VIS and short- or long-term patient outcomes in both pediatric and adult surgical patients. Meta-analysis was performed using RevMan Manager version 5.3, and quality assessment followed the Joanna Briggs Institute (JBI) Critical Appraisal Checklists.

RESULTS

A total of 58 studies comprising 29,920 patients were included in the systematic review, 34 of which were eligible for meta-analysis. Early postoperative VIS was found to be associated with prolonged mechanical ventilation (OR 5.20, 95% CI 3.78-7.16), mortality (OR 1.08, 95% CI 1.05-1.12), acute kidney injury (AKI) (OR 1.26, 95% CI 1.13-1.41), poor outcomes (OR 1.02, 95% CI 1.01-1.04), and length of stay (LOS) in the ICU (OR 3.50, 95% CI 2.25-5.44). The optimal cutoff value for the VIS as an outcome predictor varied between studies, ranging from 10 to 30.

CONCLUSION

Elevated early postoperative VIS is associated with various adverse outcomes, including acute kidney injury (AKI), mechanical ventilation duration, mortality, poor outcomes, and length of stay (LOS) in the ICU. Monitoring the VIS upon return to the Intensive Care Unit (ICU) could assist medical teams in risk stratification, targeted interventions, and parent counseling.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022359100.

Review of the allocation criteria for heart transplant in Spain in 2023. SEC-Heart Failure Association/ONT/SECCE consensus document

Heart transplant (HT) remains the best therapeutic option for patients with advanced heart failure (HF). The allocation criteria aim to guarantee equitable access to HT and prioritize patients with a worse clinical status. To review the HT allocation criteria, the Heart Failure Association of the Spanish Society of Cardiology (HFA-SEC), the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the National Transplant Organization (ONT), organized a consensus conference involving adult and pediatric cardiologists, adult and pediatric cardiac surgeons, transplant coordinators from all over Spain, and physicians and nurses from the ONT. The aims of the consensus conference were as follows: a) to analyze the organization and management of patients with advanced HF and cardiogenic shock in Spain; b) to critically review heart allocation and priority criteria in other transplant organizations; c) to analyze the outcomes of patients listed and transplanted before and after the modification of the heart allocation criteria in 2017; and d) to propose new heart allocation criteria in Spain after an analysis of the available evidence and multidisciplinary discussion. In this article, by the HFA-SEC, SECCE and the ONT we present the results of the analysis performed in the consensus conference and the rationale for the new heart allocation criteria in Spain.

Preliminary study on the predictive value of the vasoactive-inotropic score for the prognosis of neonatal congenital diaphragmatic hernia

BACKGROUND

No study has reported on the relationship between the vasoactive-inotropic score (VIS) and the prognosis of neonates with a severe congenital diaphragmatic hernia (CDH). This study aimed to identify potential risk factors for mortality in patients with CDH. We calculated the VIS based on the vasoactive drugs used during the perioperative period to investigate the relationship between VIS and infant prognosis.

METHODS

We retrospectively analyzed the clinical data of 75 neonates with CDH who were treated at our center between January 2016 and October 2021. We calculated the maximum and mean VIS during the first 24 h of hospitalization (hosVIS [24max] and hosVIS [24mean], respectively) and after surgery (postVIS [24max] and postVIS [24mean], respectively). The relationship between the VIS and the prognosis of neonates with CDH was analyzed using a receiver operating characteristic (ROC) curve, t-test, chi-square test, rank-sum test, and logistic regression analysis.

RESULTS

In total, 75 participants with CDH were included in the study. The chance of survival was 80%. Our results showed that hosVIS (24max) was an accurate predictor of prognosis (area under the ROC curve = 0.925, p = 0.007). The calculated optimal critical value of hosVIS (24max) for predicting a poor prognosis was 17 (J = 0.75). Multivariate analysis revealed that hosVIS (24max) was an independent risk factor for death in neonates with CDH.

CONCLUSION

In neonates with CDH, a higher VIS, especially hosVIS (24max), suggests worsened cardiac function, a more severe condition, and a higher risk of death. The rising VIS score in infants prompts physicians to implement more aggressive treatment to improve cardiovascular function.

Vasoactive-inotropic score/inotropic score and short-term outcomes in pediatrics undergoing cardiac surgery: A retrospective analysis from single center

BACKGROUND AND AIM OF THE STUDY

This study aimed to investigate the association between vasoactive-inotropic score/inotropic score (VIS/IS) and short-term outcomes in pediatric patients after cardiac surgery at a tertiary care center in an unselected pediatric population in China.

METHODS

This study carried out retrospective observation of 401 patients between April and June 2021 at a tertiary care center. VIS and IS were assessed intraoperatively (VIS-op, IS-op) and 2 h (VIS2h, IS2h), 24 h (VIS24h, IS24h), and 48 h (VIS48h, IS48h) postoperatively. The primary outcome was prolonged mechanical ventilation (PMV). Secondary outcomes included poor prognosis and length of stay in the pediatric intensive care unit and hospital.

RESULTS

Mean age of the included pediatric patients was 26.5 months. Pediatric cardiac procedures were performed within an average operation duration of 167.6 ± 70.8 min. Overall, the PMV group (n = 93) experienced significantly longer ACC duration, cardiopulmonary bypass duration, operation duration, and a higher prevalence of fluid accumulation overload than the non-PMV group (n = 93). Multivariate logistic regression analysis revealed that longer operation duration (odds ratio [OR]: 1.015; 95% confidence interval [95% CI]: 1.003, 1.026; p = .012) and higher VIS48h (OR: 1.188; 95% CI: 1.077, 1.311; p = .001) were strongest predictors for PMV. VIS48h had better discrimination power for PMV than other time intervals, and the area under the curve was 0.780 (95% CI, 0.721, 0.839; p = .000).

CONCLUSIONS

VIS48h independently predicted short-term outcomes after cardiac surgery in an unselected pediatric population in China and showed better prediction accuracy and discrimination capability than other time intervals.

Vasoactive inotropic score as a predictor of long-term mortality in patients after off-pump coronary artery bypass grafting

Increased vasoactive-inotropic score (VIS) is a reliable predictor of mortality and morbidity after cardiac surgery. Here, we retrospectively evaluated the association between VIS and adverse outcomes in adult patients after off-pump coronary artery bypass grafting (OPCAB). We included 2149 patients who underwent OPCAB. The maximal VIS was calculated for the initial 48 postoperative hours using standard formulae. The primary outcome was 1-year death. The composite adverse outcome was death, resuscitation or mechanical support, myocardial infarction, revascularization, new-onset atrial fibrillation, infection requiring antibacterial therapy, acute kidney injury, and stroke. Path-analysis was conducted using lactate and prognostic nutritional index (PNI). VIS was associated with 1-year death (odds ratio [OR] 1.07 [1.04–1.10], p < 0.001) and 1-year composite outcome (OR 1.02 [1.0–1.03], p = 0.008). In path-analysis, high VIS showed a direct effect on the increased risk of 1-year death and composite outcome. In the pathway using lactate as a mediating variable, VIS showed an indirect effect on the composite outcome but no significant effect on death. Low PNI directly affected the increased risk of 1-year death and composite outcome, and had an indirect effect on both outcomes, even when VIS was used as a mediating variable. In patients undergoing OPCAB, high VIS independently predicted morbidity and 1-year death. Patients with increased lactate levels following high VIS had an increased risk of postoperative complications, although not necessarily resulting in death. However, patients with poor preoperative nutritional status had an increased risk of unfavourable outcomes, including death, implying the importance of preoperative nutritional support.

Outcomes of a multidisciplinary mechanical circulatory support network in cardiogenic shock in a centre without heart transplant program: A successful interprofessional coordination model

BACKGROUND AND OBJECTIVE

Cardiogenic shock (CS) mortality remains very high and mechanical circulatory support (MCS) may provide an effective alternative of treatment in selected patients. The aim of this study is to analyse the results of a multidisciplinary team care program (including anaesthesiologists, cardiologists, cardiothoracic surgeons, and intensivists) in CS patients who required MCS, in a tertiary centre without a heart transplant (HT) program.

METHODS

Prospective observational study that sought to analyse the characteristics and survival to discharge predictors in a consecutive CS patients cohort treated with MCS.

RESULTS

A total of 48 patients were included. Mean age was 61 ± 14 years. Before MCS, 45.8% of the patients presented with cardiac arrest. A 54.2% 30-day survival and 45.8% overall survival to discharge, was found. Age and vasoactive-inotropic score were independent predictors of mortality.

CONCLUSIONS

A multidisciplinary team-care based MCS program in CS patients is feasible and may achieve favourable results in a centre without HT program.

Vasoactive-Inotropic Score as a Determinant of Timely Initiation of Venoarterial Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock

BACKGROUND

The predictive role of the vasoactive-inotropic score (VIS) for clinical outcomes after venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock is not well known. This study investigated the predictive value of VIS on in-hospital outcomes and the determination of optimal timing for the initiation of VA-ECMO.Methods and Results:Overall, 160 patients with cardiogenic shock requiring VA-ECMO who were treated between December 2012 and August 2018 were analyzed. The in-hospital outcomes according to VIS were compared. Pre-ECMO VIS had an area under the receiver-operating characteristic curve (AUC) of 0.60 (P=0.03) for the prediction of in-hospital death. When the patients were divided into the high (≥32) and low (<32) VIS groups, the high VIS group had a higher rate of in-hospital death (P=0.002) and a lower rate of ECMO weaning (P=0.004). The difference in in-hospital death according to VIS was significant only in patients with a cardiogenic shock of non-ischemic etiology (P=0.01). Extracorporeal cardiopulmonary resuscitation (hazard ratio [HR], 1.99), age (HR, 1.02), pre-ECMO lactate (HR, 1.06), and VIS ≥32 (HR, 2.46) were independently predictive of in-hospital death.

CONCLUSIONS

Among patients with cardiogenic shock requiring VA-ECMO, the initiation of VA-ECMO before reaching high VIS (≥32) showed better in-hospital outcomes, suggesting that VIS may be a potential marker for determining the initiation of hemodynamic support with VA-ECMO.

Post-transplant inotrope score is associated with clinical outcomes after adult heart transplantation

BACKGROUND

Inotrope score has been proposed as a marker of clinical outcome after adult heart transplantation (HTx) but is rarely used in practice.

METHODS

Inotrope score during the first 48 h after HTx was calculated in 81 patients as: dopamine + dobutamine + amrinone + milrinone (dose × 15) + epinephrine (dose × 100) + norepinephrine (dose × 100) + enoximone + isoprenaline (dose × 100), with each drug in µg/kg/min. Determinants of inotrope score were identified with linear regression. Cox regression was used to determine the association of inotrope score with mortality.

RESULTS

The mean recipient age was 52 ± 11 years, and 32 (39.5%) patients were female. Determinants of inotrope score were preoperative C-reactive protein, serum urea, congenital heart disease, and donor cardiac arrest (R2  = .30). Inotrope score was associated with 5-year mortality, independent of recipient age and gender (HR 1.03, 95% CI 1.00-1.07). This association was attenuated when adjusting for female-to-male transplant and ischemia time. Inotrope score was also strongly associated with continuous veno-venous hemofiltration (OR 1.07, 95% CI 1.03-1.12).

CONCLUSION

High inotrope score post-HTx was observed in recipient congenital heart disease and was associated with a higher risk of mortality and acute kidney injury.

Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study

Background

Therapeutic extracorporeal membrane oxygenation (ECMO) is a challenging procedure in patients who have experienced severe trauma. Particularly, patients with traumatic lung injury and posttraumatic acute respiratory distress syndrome (ARDS) have a high risk of bleeding during this procedure. This study aimed to determine the safety and feasibility of ECMO in patients with traumatic ARDS.

Methods

We retrospectively reviewed medical records and investigated the clinical outcomes of ECMO in 42 patients with traumatic ARDS, among whom near-drowning (42.9%) was the most frequent cause of injury.

Results

Thirty-four of 42 patients (81%) survived and were discharged after a median hospital stay of 23 days. A multivariate analysis identified a lactate level (odds ratio: 1.493, 95% confidence interval: 1.060–2.103, P = 0.022) and veno-venous (VV) ECMO (odds ratio: 0.075, 95% confidence interval: 0.006–0.901, P = 0.041) as favorable independent predictors of survival in patients with traumatic ARDS who underwent ECMO. The optimal cut off value for pre-ECMO lactate level was 10.5 mmol/L (area under the curve = 0.929, P = 0.001). In Kaplan-Meier analysis, the survival rate at hospital discharge was significant higher among the patients with a pre-ECMO lactate level of 10.5 mmol/L or less compared with patients with pre-ECMO lactate level greater than 10.5 mmol/L (93.8% versus 40.0%, respectively; P = 0.01).

Conclusions

ECMO yielded excellent survival outcomes, particularly in patients with low pre-treatment lactate levels who received VV ECMO. Therefore, ECMO appears safe and highly feasible in a carefully selected population of trauma patients.

Effect of initial infusion rates of fluid resuscitation on outcomes in patients with septic shock: a historical cohort study

Background

Fluid resuscitation has become the cornerstone of early septic shock management, but the optimal fluid rate is still not well studied. The goal of this investigation is to examine the relationship between fluid resuscitation rate and septic shock resolution.

Method

We retrospectively studied adult (≥ 18 years) patients with septic shock, defined based on sepsis III definition, from January 1, 2006, through May 31, 2018, in the medical intensive care unit (MICU) of Mayo Clinic Rochester. The fluid resuscitation time was defined as the time required to infuse the initial fluid bolus of 30 ml/kg, based on the recommendations of the 2016 surviving sepsis campaign. The cohort was divided into four groups based on the average fluid rate (group 1 ≥ 0.5, group 2 0.25–0.49, group 3 0.17–0.24, and group 4 < 0.17 ml/kg/min). The primary outcome was the time to shock reversal. Multivariable regression analyses were conducted to account for potential confounders.

Result

A total of 1052 patients met eligibility criteria and were included in the analysis. The time-to-shock reversal was significantly different among the groups (P < .001). Patients in group 1 who received fluid resuscitation at a faster rate had a shorter time to shock reversal (HR = 0.78; 95% CI 0.66–0.91; P = .01) when compared with group 4 with a median (IQR) time-to-shock reversal of 1.7 (1.5, 2.0) vs. 2.8 (2.6, 3.3) days, respectively. Using 0.25 ml/kg/min as cutoff, the higher fluid infusion rate was associated with a shorter time to shock reversal (HR = 1.22; 95% CI 1.06–1.41; P = .004) and with decreased odds of 28-day mortality (HR = 0.71; 95% CI 0.60–0.85; P < .001).

Conclusion

In septic shock patients, initial fluid resuscitation rate of 0.25–0.50 ml/kg/min (i.e., completion of the initial 30 ml/kg IV fluid resuscitation within the first 2 h), may be associated with early shock reversal and lower 28-day mortality compared with slower rates of infusion.

30-Day Outcomes Post Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO) After Cardiac Surgery and Predictors of Survival

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is sometimes needed for post-cardiotomy cardiogenic shock (PCCS). There is little data regarding outcomes in the Australian context, particularly in a non-cardiac transplant centre. Our aim was to report on 30-day outcomes after patients with PCCS treated with VA-ECMO in an Australian non-cardiac transplant tertiary centre, and to determine risk factors for non-survival in this population.

METHODS

A retrospective analysis was performed on all adults treated with VA-ECMO for PCCS between August 2001 and September 2016 at our centre. Univariate analysis with adjustment for multiplicity identified risk factors for non-survival. Area under the receiver operating characteristics (AUROC) method was used to assess their predictive value.

RESULTS

We identified 64 patients out of 5,502 open-heart surgery cases of which three patients did not meet inclusion criteria. Mean (SD) age was 63 (14) years. Survival to hospital discharge or 30 days post VA-ECMO occurred in 27/61 (44%) patients. VA-ECMO was able to be weaned in 44/61 patients (72%); 54/61 patients (89%) had at least one major complication. Prior to VA-ECMO initiation, no statistically significant differences between survivors and non-survivors could be determined. After VA-ECMO initiation, only 24-hour nadir lactate and 48-hour nadir lactate levels were significantly different between survivors and non-survivors (1.50 mmol/L vs 3.20 mmol/L p=0.001; and 1.20 mmol/L vs. 1.90 mmol/L p=0.001 respectively). For mortality prediction, 24- and 48-hour nadir lactate levels had AUROCs of 0.775 and 0.782, respectively.

CONCLUSIONS

VA-ECMO is associated with acceptable survival rates but significant morbidity. Nadir lactate levels in the first 24 and 48 hours after VA-ECMO initiation may be useful in predicting early survival.

Risk factors for noninvasive ventilation failure in patients with post-extubation acute respiratory failure after cardiac surgery

Background

The effect of noninvasive ventilation (NIV) in patients with acute respiratory failure (ARF) after cardiac surgery is controversial. This study identified the feasibility of NIV and assessed the risk factors of NIV failure in patients with ARF after cardiac surgery.

Methods

We retrospectively reviewed data from 112 patients with ARF requiring NIV and categorized them into the NIV failure and success groups. Patient data were extracted for further analysis, the primary outcomes were the need for endotracheal intubation and NIV-related in-hospital mortality. The risk factors for NIV failure in patients with post-extubation ARF was analyzed.

Results

The median time from extubation to NIV was 11 hours. No difference in the EuroSCORE existed between the two groups. NIV failed in 38.4% of the patients. The NIV failure group had a higher in-hospital mortality and stay at the longer intensive care unit (ICU). Most cases of NIV failure occurred within 1-48 hours of the treatment. The main causes of early NIV failure were a weak cough reflex and/or excessive secretions and hemodynamic instability. A Sequential Organ Failure Assessment (SOFA) score ≥10.5, vasoactive-inotropic score ≥6, and pneumonia were predictors of NIV failure, whereas a body mass index (BMI) ≥25.0 kg/m² predicted NIV success.

Conclusions

NIV was effective in the study population. Multiple organ dysfunction, pneumonia, and significant inotropic drug support before NIV were associated with NIV failure, whereas a BMI ≥25 kg/m² was a predictor of NIV success.

Prognostic Value of Serum Lactate Levels in Patients Undergoing Urgent Heart Transplant: A Subanalysis of the ASIS-TC Spanish Multicenter Study

INTRODUCTION AND OBJECTIVES

To study the prognostic value of serum lactate in patients under temporary preoperative mechanical circulatory support who underwent urgent heart transplant.

METHODS

We conducted a subanalysis of a Spanish multicenter registry recording data on patients under temporary mechanical circulatory support listed for highly urgent heart transplant from 2010 to 2015. Participants selected for the present study were those who received a transplant and who had known preoperative serum lactate levels. The main study outcome was 1-year survival after transplant.

RESULTS

A total of 177 heart transplant recipients were studied; preoperatively, 90 were supported on venoarterial extracorporeal membrane oxygenation, 51 on temporary left ventricular assist devices, and 36 on temporary biventricular assist devices. Preoperative hyperlactatemia (≥ 2 mmol/L) was present in 44 (25%) patients. On multivariable analysis, pretransplant serum lactate was identified as an independent predictor of 1-year posttransplant survival (adjusted HR per 0.1 mmol/L, 1.02; 95%CI, 1.01-1.03; P = .007). One-year posttransplant survival was 53.1% (95%CI, 45.3-60.9) in patients with preoperative hyperlactatemia and 75.6% (95%CI, 71.8-79.4) in those without preoperative hyperlactatemia (adjusted HR, 1.94; 95%CI, 1.04-3.63; P = .039). Preoperative hyperlactatemia correlated with adverse outcomes in patients supported with extracorporeal membrane oxygenation, but not in patients supported on ventricular assist devices.

CONCLUSIONS

Preoperative serum lactate is a strong independent predictor of worse outcomes in patients undergoing urgent heart transplant on short-term mechanical circulatory support.

Vasoactive Inotropic Score as a Predictor of Mortality in Adult Patients With Cardiogenic Shock: Medical Therapy Versus ECMO

INTRODUCTION AND OBJECTIVES

This study investigated whether the vasoactive inotropic score (VIS) is independently predictive of mortality in cardiogenic shock (CS).

METHODS

This study was retrospective, observational study. Patients who were admitted to the cardiac intensive care unit from January 2012 to December 2015 were screened, and 493 CS patients were finally enrolled. To quantify pharmacologic support, the patients were divided into 5 groups based on a quintile of VIS: 1 to 10, 11 to 20, 21 to 38, 39 to 85, and > 85. The primary outcome was in-hospital mortality.

RESULTS

In-hospital mortalities in the 5 VIS groups in increasing order were 8.2%, 14.1%, 21.1%, 32.0%, and 65.7%, respectively (P < .001). Multivariable analysis indicated that VIS ranges of 39 to 85 (aOR, 3.85; 95%CI, 1.60-9.22; P = .003) and over 85 (aOR, 10.83; 95%CI, 4.43-26.43; P < .001) remained significant prognostic predictors for in-hospital mortality. With multiple logistic regression to remove any confounding effects, we found that the localized regression lines regarding the odds of death intersected each other's (medical therapy alone and combined extracorporeal membrane oxygenation group) path at VIS = 130. In contrast to linear correlation between VIS and mortality for patients treated with medical therapy alone, there was little association between a VIS of 130 or more and the probability of in-hospital mortality for patients who were treated with extracorporeal membrane oxygenation.

CONCLUSIONS

A high level of vasoactive inotropic support during the first 48hours was significantly associated with increased in-hospital mortality in adult CS patients.

[Association between vasoactive-inotropic score and prognosis in children with septic shock]

OBJECTIVE

To investigate the association between vasoactive-inotropic score (VIS) and prognosis in children with septic shock.

METHODS

A total of 117 children with decompensated septic shock who received the treatment with vasoactive agents were enrolled. According to their prognosis, they were divided into death group with 41 children and survival group with 76 children. With the maximum VIS within the first 24 hours (24hVIS max) as the cut-off value (29.5), the children were divided into low VIS group with 78 children and high VIS group with 39 children. The 24hVIS max and the mean VIS within the first 24 hours (24hVIS mean) were calculated for all children. A receiver operating characteristic (ROC) curve analysis was performed for the association between VIS and the prognosis of septic shock.

RESULTS

Compared with the survival group, the death group had significantly higher 24hVIS max, 24hVIS mean, PRISM III score, and level of lactate before the use of vasoactive agents and after 24 hours of use (P<0.05). 24hVIS max, 24hVIS mean, PRISM III score, level of lactate before the use of vasoactive agents and after 24 hours of use, and 24-hour pH had a certain value in predicting the prognosis of septic shock, but 24hVIS max had the largest area under the ROC curve. Compared with the low VIS group, the high VIS group had significantly higher number of deaths, PRISM III score, and level of lactate before treatment and after 24 hours of treatment (P<0.05).

CONCLUSIONS

VIS is associated with the mortality of children with septic shock, and the severity and mortality of patients increase with the increase in VIS.

Clinical outcomes of temporary mechanical circulatory support as a direct bridge to heart transplantation: a nationwide Spanish registry

BACKGROUND

In Spain, listing for high-urgent heart transplantation is allowed for critically ill candidates not weanable from temporary mechanical circulatory support (T-MCS). We sought to analyse the clinical outcomes of this strategy.

METHODS AND RESULTS

We conducted a case-by-case, retrospective review of clinical records of 291 adult patients listed for high-urgent heart transplantation under temporary devices from 2010 to 2015 in 16 Spanish institutions. Survival after listing and adverse clinical events were studied. At the time of listing, 169 (58%) patients were supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO), 70 (24%) on temporary left ventricular assist devices (T-LVAD) and 52 (18%) on temporary biventricular assist devices (T-BiVAD). Seven patients transitioned from VA-ECMO to temporary ventricular assist devices while on the waiting list. Mean time on T-MCS was 13.1 ± 12.6 days. Mean time from listing to transplantation was 7.6 ± 8.5 days. Overall, 230 (79%) patients were transplanted and 54 (18.6%) died during MCS. In-hospital postoperative mortality after transplantation was 33.3%, 11.9% and 26.2% for patients bridged on VA-ECMO, T-LVAD and T-BiVAD, respectively (P = 0.008). Overall survival from listing to hospital discharge was 54.4%, 78.6% and 55.8%, respectively (P = 0.002). T-LVAD support was independently associated with a lower risk of death over the first year after listing (hazard ratio 0.52, 95% confidence interval 0.30-0.92). Patients treated with VA-ECMO showed the highest incidence rate of adverse clinical events associated with T-MCS.

CONCLUSION

Temporary devices may be used to bridge critically ill candidates directly to heart transplantation in a setting of short waiting list times, as is the case of Spain. In our series, bridging with T-LVAD was associated with more favourable outcomes than bridging with T-BiVAD or VA-ECMO.

Clinical implications of hypothermic ventricular fibrillation versus beating-heart technique during cardiopulmonary bypass for pulmonary valve replacement in patients with repaired tetralogy of Fallot

OBJECTIVES

This study aimed to compare the effects of hypothermic ventricular fibrillation and beating-heart techniques during cardiopulmonary bypass (CPB) on postoperative outcomes after simple pulmonary valve replacement in patients with repaired tetralogy of Fallot (TOF).

METHODS

We retrospectively reviewed the data of 47 patients with repaired tetralogy of Fallot at a single institution, who received pulmonary valve replacement under the ventricular fibrillation or beating-heart technique without cardioplegic cardiac arrest during CPB between January 2005 and April 2015.

RESULTS

The patients were divided into fibrillation (n = 32) and beating-heart (n = 15) groups. On comparing these groups, the fibrillation group had a larger sinotubular junction (27.1 ± 4.6 vs 22.1 ± 2.4 mm), had a longer operation duration (396 ± 108 vs 345 ± 57 min), required more postoperative transfusions (2.1 ± 2.6 vs 5.0 ± 6.3 units) and had a higher vasoactive-inotropic score at intensive care unit admission (8.0 vs 10, all P < 0.05). Echocardiographic data indicated that the systolic internal diameter of the left ventricle was larger in the fibrillation group than in the beating-heart group immediately after surgery and at the 1-year follow-up. Major adverse cardiac events occurred in 3 cases, all from the fibrillation group. Among 7 patients from the fibrillation group with transoesophageal echocardiography data during CPB, 6 had fully opened aortic valves during fibrillation, causing flooding into the left ventricle and left ventricle distension.

CONCLUSIONS

The postoperative outcomes are worse with the ventricular fibrillation technique than with the beating-heart technique during CPB for pulmonary valve replacement in patients with repaired tetralogy of Fallot.