Destination Therapy with Ventricular Assist Devices

Abstract

Despite extensive research and great strides over the past 40 years, the ideal permanent mechanical assist device remains elusive. The incidence of heart failure is increasing, and the number of heart transplants has remained constant. The HeartMate and Novacor are two pulsatile, long-term ventricular assist devices (VADs) commonly used as a bridge to transplantation. Randomized Evaluation of Mechanical Assistance in the Treatment of Congestive Heart Failure is a randomized study of device therapy in heart failure with treatment either with device (HeartMate) therapy or maximal medical therapy which was recently completed and demonstrated a Kaplan-Meier survival rate at 1 year of 52% for the device group compared to 25% in the medical therapy group. The TCI HeartMate is the only device approved for destination therapy, while others such as the Novacor device are in the process of evaluation. Most of these devices are still plagued by mechanical problems, bleeding, thromboembolism and infection. Other promising new devices include smaller VADs using impeller pump technology, such as the Arrow LionHeart, Micromed Debakey pump and Jarvik 2000 pump. The CardioVAD is an interesting chronically implantable balloon pump inserted into the descending thoracic aorta. While experience with the newer implantable pumps is growing, most of them require some manipulation of the heart perioperatively, in addition to anticoagulation postoperatively and careful monitoring for complications and infection.

Peripheral blood mononuclear cell transcriptome profiles suggest T-cell immunosuppression after uncomplicated mechanical circulatory support device surgery

“…Virtually all currently available MCSD require percutaneous drivelines [17]. This creates an important mechanism for MCSD infection, making a diagnostic test likely useful for the foreseeable future.…”

Neurologic Events With a Totally Implantable Left Ventricular Assist Device: European LionHeart Clinical Utility Baseline Study (CUBS)

“…13 From October 1999 to December 2002, 23 male patients were implanted with the LionHeart LVAD at 10 European centers. Each patient was diagnosed with NYHA Class IV heart failure and was ineligible for, or unlikely to receive, heart transplantation.…”

Complications in Patients With Ventricular Assist Devices

“…9 The high rates of infections among patients with VAD may be related to the fact that the patients are already malnourished and weakened preoperatively and, therefore, more susceptible to pathogens. 19 The patients with VAD are also vulnerable to device-related infections because the device's percutaneous drivelines are exposed to outside pathogens. Furthermore, the devices have many cavities and pockets that harbor microorganisms.…”