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

Abstract

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.

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  • Authors+Show Affiliations

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    Department of Medicine, Stanford University Medical Center, Stanford, California.

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    Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota.

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    Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.

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    Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.

    Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York. Electronic address: my2249@cumc.columbia.edu.

    Source

    Pub Type(s)

    Journal Article

    Language

    eng

    PubMed ID

    31201088

    Citation

    Han, Jiho, et al. "Prognostic Value of Vasoactive-inotropic Score Following Continuous Flow Left Ventricular Assist Device Implantation." The Journal of Heart and Lung Transplantation : the Official Publication of the International Society for Heart Transplantation, 2019.
    Han J, Pinsino A, Sanchez J, et al. Prognostic value of vasoactive-inotropic score following continuous flow left ventricular assist device implantation. J Heart Lung Transplant. 2019.
    Han, J., Pinsino, A., Sanchez, J., Takayama, H., Garan, A. R., Topkara, V. K., ... Yuzefpolskaya, M. (2019). Prognostic value of vasoactive-inotropic score following continuous flow left ventricular assist device implantation. The Journal of Heart and Lung Transplantation : the Official Publication of the International Society for Heart Transplantation, doi:10.1016/j.healun.2019.05.007.
    Han J, et al. Prognostic Value of Vasoactive-inotropic Score Following Continuous Flow Left Ventricular Assist Device Implantation. J Heart Lung Transplant. 2019 May 24; PubMed PMID: 31201088.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Prognostic value of vasoactive-inotropic score following continuous flow left ventricular assist device implantation. AU - Han,Jiho, AU - Pinsino,Alberto, AU - Sanchez,Joseph, AU - Takayama,Hiroo, AU - Garan,A Reshad, AU - Topkara,Veli K, AU - Naka,Yoshifumi, AU - Demmer,Ryan T, AU - Kurlansky,Paul A, AU - Colombo,Paolo C, AU - Takeda,Koji, AU - Yuzefpolskaya,Melana, Y1 - 2019/05/24/ PY - 2018/12/18/received PY - 2019/03/06/revised PY - 2019/05/17/accepted PY - 2019/6/16/entrez KW - in-hospital mortality KW - inotropes KW - trimethylamine-N-oxide KW - vasopressors KW - ventricular assist device JF - The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation JO - J. Heart Lung Transplant. N2 - 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. SN - 1557-3117 UR - https://www.unboundmedicine.com/medline/citation/31201088/Prognostic_value_of_vasoactive-inotropic_score_following_continuous_flow_left_ventricular_assist_device_implantation L2 - https://linkinghub.elsevier.com/retrieve/pii/S1053-2498(19)31511-6 DB - PRIME DP - Unbound Medicine ER -