Role of a Percutaneous Ventricular Assist Device in Decision Making for a Cardiac Transplant Program

Medical City Dallas Hospital, Dallas, Texas 75230, USA.
The Annals of thoracic surgery (Impact Factor: 3.65). 11/2009; 88(5):1462-6. DOI: 10.1016/j.athoracsur.2009.07.015
Source: PubMed

ABSTRACT The role of a percutaneous ventricular assist device (VAD) for left heart support in the management of patients in cardiogenic shock is not well defined.
All patients who received LV support using the percutaneous TandemHeart (percTH) ventricular support device (Cardiac Assist, Pittsburgh, PA) were retrospectively reviewed. Indications for insertion included bridge to decision (BTD) or "salvage" and bridge to transplant (BTT).
Between April 2005 and December 2008, 22 percTH devices were successfully implanted in patients (13 men) with isolated left heart failure. Mean duration of support was 6.8 +/- 9.4 days (median, 4; maximum, 45 days). Of patients requiring percTH support for at least 3 days, mean pump flows were 3.77 +/- 1.10, 4.22 +/- 0.69, and 4.04 +/- 0.41 L/min on at days 1, 2, and 3. Mean serum aspartate aminotransferase levels were 455 +/- 994 mg/dL before percTH, 551 +/- 1046 mg/dL at day 1, and 231 +/- 225 mg/dL at day 3 after percTH. No mechanical device failure, device-related infections, or cerebrovascular accidents occurred. Ten of 11 BTT patients were successfully bridged. Support was withdrawn in 7 of 11 BTD patients. The percTHs were successfully explanted in 4 BTD patients: 1 as recovery, 1 direct to transplant, and 2 to VAD.
The percTH was reliable, with no mechanical device failures and minimal associated adverse events. We support the use of the percTH in the BTD mode, allowing time for a more complete evaluation of neurologic and end-organ status without the added expense and morbidity of a long-term VAD.

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    • "In the early periods of LVADs, the hospital and insurance company had contracts that were in favor of the insurance company. Therefore, hospitals had to be prepared for a fairly large financial loss when they installed LVADs [37] [38]. In Japan, Novacor (Rueil- Malmaison, France) was approved by insurance agencies as BTT appropriate in 2004. "
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    ABSTRACT: Until 2010, Japan had been using the Toyobo (Nipro, Osaka, Japan) extracorporeal left ventricular assist device (VAD) developed 30 years ago as a 2-3 year bridge to transplantation (BTT). In contrast, western nations started to use implantable VADs in the 1980s that allow in-home care as destination therapy (DT) as well as BTT. Designated in 2007 as "medical devices in high demand," the 5 major implantable mechanical hearts are smoothly undergoing clinical testing. The HeartMate XVE (Thoratec Corp., Pleasanton, CA, USA) gained approval from the Ministry of Health in November of 2009, the DuraHeart (TerumoHeart, Ann Arbor, MI, USA) and EVAHEART (Sun Medical, Nagano, Japan) in December 2010, and obtained formal insurance reimbursement in April 2011. The Jarvik 2000 (Jarvik Heart Inc., New York, NY, USA) and HeartMate II (Thoratec) VADs are pending approval. On the other hand, the organ transplantation law allowing explantation of donor organs from brain-dead patients finally passed in July 2009 and was realized in July 2010. This law paved the way to pediatric heart transplants as well as a dramatic increase in overall organ transplantation cases. Because many juvenile patients awaiting donor organs need a VAD as a long-term bridge, development and clinical introduction of pediatric VADs capable of implantation is an exigency. Although expectations for transplants are high, the donor numbers are low. Therefore, the demand for implantable VADs capable of long-term home treatment is extremely high in Japan.
    Journal of Cardiology 03/2012; 59(2):101-9. DOI:10.1016/j.jjcc.2012.01.001 · 2.57 Impact Factor
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    • "This being when the assistance device supports the failing heart in potentially reversible causes of shock such as myocarditis, drug overdose, hypothermia, coronarography-related complications (air embolism, no-reflow phenomenon, and dissections), incessant arrhythmia, or postcardiotomy syndrome. Similarly, pVADs are reliable and used until more definitive measures can be undertaken such as long-term surgical device implantation (bridge-to-bridge) and transplantation (bridge-to-transplantation) [26, 27]. "
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    ABSTRACT: The development of ventricular assist devices has broadened the means with which one can treat acute heart failure. Percutaneous ventricular assist devices (pVAD) have risen from recent technological advances. They are smaller, easier, and faster to implant, all important qualities in the setting of acute heart failure. The present paper briefly describes the functioning and assets of the most common devices used today. It gives an overview of the current evidence and indications for left ventricular assist device use in cardiogenic shock and high-risk percutaneous coronary intervention. Finally, extracorporeal life support devices are dealt with in the setting of hemodynamic support.
    Minimally Invasive Surgery 07/2011; 2011:604397. DOI:10.1155/2011/604397
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    ABSTRACT: While great strides have been made in the management of heart failure syndromes, acute refractory cardiogenic shock carries a dismal prognosis. Initial treatment with inotropes and balloon counterpulsation can restore hemodynamics, but many patients deteriorate and succumb to multisystem organ failure if timely mechanical circulatory support is not established. Institution of support is intended as a life-saving measure where the final treatment strategy remains uncertain. This scenario is referred to as "bridge to decision." Notably, most of these patients present to community hospitals, where advanced mechanical support technologies are scarce or nonexistent. Delays in referral to a tertiary center contribute to the bleak outcomes. Herein, we review the initial management of acute heart failure and refractory cardiogenic shock, profile the typical patient, delineate current options for mechanical support in patients with acute refractory cardiogenic shock, and propose suggestions for the establishment of a seamless transfer process of these ill patients to tertiary centers.
    Current Heart Failure Reports 03/2011; 8(1):51-8. DOI:10.1007/s11897-010-0041-5
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