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CLINICAL STUDY: ACUTE CORONARY SYNDROME

Severe renal dysfunction complicating cardiogenic shock is not a contraindication to mechanical support as a bridge to cardiac transplantation

Umesh N. Khot, MD^*,*, Micky Mishra, MD, M. Hilal Yamani, MD^*, Nicholas G. Smedira, MD, FACC, Emil Paganini, MD, Mike Yeager, RN, Tiffany Buda, RN, Patrick M. McCarthy, MD, James B. Young, MD, FACC^* and Randall C. Starling, MD, MPH, FACC^*

^* Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, , Cleveland, Ohio, USA
Department of Internal Medicine, Cleveland, Ohio, USA
Department of Nephrology and Hypertension, Cleveland, Ohio, USA
Department of Cardiothoracic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received March 28, 2002; revised manuscript received September 28, 2002, accepted November 1, 2002.

^* Reprint requests and correspondence: Dr. Umesh N. Khot, Indiana Heart Physicians, 112 North 17th Avenue, Suite 300, Beech Grove, Indiana 46107, USA.
khot{at}cvresearch.net

OBJECTIVES: This study investigated outcomes in patients with cardiogenic shock and severe renal dysfunction treated with ventricular assist devices (VAD) as a bridge to cardiac transplantation.

BACKGROUND: Previous reports have documented poor survival in patients with cardiogenic shock and severe renal dysfunction treated with VAD.

METHODS: We surveyed 215 consecutive patients who received a VAD from 1992 to 2000 and selected patients who had a serum creatinine 3.0 mg/dl at the time of VAD placement. Demographic, laboratory, and clinical outcome data were collected.

RESULTS: Eighteen patients met the inclusion criteria. Mean serum creatinine at the time of VAD placement was 4.0 ± 0.7 mg/dl (range 3.0 to 5.2 mg/dl). Seven patients required temporary renal support with continuous venovenous hemodialysis (CVVHD). Eleven patients underwent cardiac transplantation. At six months post-transplantation, mean serum creatinine was 2.0 ± 0.6 mg/dl (range 1.3 to 3.5 mg/dl). None of the transplanted patients required subsequent renal support. Seven patients died with a VAD before transplantation. Three died early (<1 month) after VAD placement, and all three required CVVHD until death. Four patients survived for >1 month after VAD placement; all four had resolution of renal dysfunction with mean serum creatinine of 1.9 ± 1.2 mg/dl (range 0.8 to 3.6 mg/dl) without the need for renal support. Overall 30-day and six-month survival after VAD placement, survival to transplantation, and survival one year post-transplantation were similar to patients without severe renal dysfunction.

CONCLUSIONS: Contemporary use of VAD leads to resolution of severe renal dysfunction in most cardiogenic shock patients and comparable long-term outcomes to patients without renal dysfunction.

Abbreviations and Acronyms   CVVHD   continuous venovenous hemodialysis   VAD   ventricular assist device(s)

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