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: 3.85). 11/2009; 88(5):1462-6. DOI: 10.1016/j.athoracsur.2009.07.015
Source: PubMed


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 Support was withdrawn in 7 of 11 BTD patients.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.
    Full-text · Article · Mar 2012 · Journal of Cardiology
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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.
    Full-text · Article · Jul 2011 · Minimally Invasive Surgery
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    ABSTRACT: Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.
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