COMMENTARY

COMMENTARY

Published: 15 June 2011

Citation: Mechanical Circulatory Support 2011, 2: 7303 - DOI: 10.3402/mcs.v2i0.7303

Mechanical Circulatory Support 2011. © 2011 Benjamin Sun. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


In their report entitled “Poor outcomes resulting from ventricular assist devices implanted in hospitals without dedicated ventricular assist device programs” (1), Dr Anyanwu and colleagues describe their experiences with 12 patients who had received ventricular assist device placement for cardiogenic shock from facilities that do not have long-term implantable device programs. They identified technical issues that contrib- uted to their poor outcomes. Their subsequent conclu- sions were that these patients should alternatively be placed on inotropes and an intra-aortic balloon pump and transferred to centers that ar more focused on mechanical support for therapy. I disagree with this approach.

Acute cardiogenic shock can be difficult to manage with conventional therapies of inotropic therapy and intra-aortic balloon pumps. The New York State shock trial demonstrated a 50%, 30-day mortality in patients with acute myocardial infarction and cardiogenic shock regardless of whether revascularization or medical management was employed (2). As the authors stated in this manuscript, the addition of mechanical circulatory support strategies have demonstrated recovery and discharged home rates in excess of 40% for some of the most critically ill in select programs (3). These relatively successful programs also received transfers from patients that were implanted from referring facilities. The successful implementation of shock programs involves ongoing dialogue and communication with all parties involved. It is unclear from this manuscript whether or not feedback to the referring centers was ever initiated. As with all developing programs, early experiences often have opportunities for improvement. As technical or management issues are identified, timely feedback is critical in improving outcomes. The education, support structure, or other care processes for mechanical support utilized in the centers that had referred to their institution may not have been adequate. These should be identified and addressed accordingly depending on the circumstances of each institution and relationship. Though there certainly are therapies that need to remain concentrated in centers of excellence, acute cardiogenic shock is seen everywhere and needs to be treated locally. Developing strategies for improving outcomes in this patient group needs to be disseminated. The use of short-term mechanical circulatory support can be an important part of stabilizing and salvaging this group. Intra-aortic balloon pumps were only instituted in major centers many years ago. It is now a ubiquitous and life-saving option. Short-term mechanical support will also evolve to be effectively utilized in the community. We should take the position of helping in that process, whether it is by education or partnership.

References

  1. Anyanwu AC, Pinney S, Hammond K, Ashley K, Adams DH. Poor outcomes resulting from ventricular assist devices implanted in hospitals without dedicated ventricular assist device programs. Mec Circ Support 2011; 2: 5974. DOI: 10.3402/mcs.v2i0.5974. [Crossref]
  2. Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, et al. Early Revascularization Improves Long-Term Survival for Cardiogenic Shock Complicating Acute Myocardial Infarction. NEJM 1999; 341: 625–34. [Crossref]
  3. Anderson M, Smedira N, Samuels L, Madani M, Naka Y, Acker M, Hout M, Benali K. Use of the AB5000 ventricular assist device in cardiogenic shock after acute myocardial infarction. Ann Thorac Surg 2010; 90: 706–12. [Crossref]

Benjamin Sun, MD, FACS
Chair, Cardiac, Thoracic and Transplant Surgery
Minneapolis Heart Institute
Allina Health Systems
920 East 28th Street, Suite 610
Minneapolis, MN 55407, USA

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Mechanical Circulatory Support eISSN 2000-6993

This journal is published under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License. Responsible editor: Michael Firstenberg.