Left Ventricular Assist Devices as Bridge to Heart Transplantation in Congestive Heart Failure with Pulmonary Hypertension

Abstract

Severe pulmonary hypertension (PH) has been considered a significant contraindication to cardiac transplantation. Ongoing clinical experience, however, has shown that temporary support using left ventricular assist devices (LVADs) in these patients can result in significant reductions in PH. A comprehensive review of the available literature regarding the use of LVADs in heart failure patients with PH was conducted. The existing literature to date supports the use of LVADs in heart failure patients with PH and demonstrates that significant reductions in PH in these patients can be achieved. This subsequently allows for safe and effective cardiac transplantation in patients who were previously excluded from this modality. For heart failure patients with severe PH, the use of LVADs can provide significant benefits by significantly reducing PH and allowing subsequent staged transplantation.

Indications for Heart Transplantation in Pediatric Heart Disease

“…194 Furthermore, utilization of ventricular assist devices for mechanical circulatory support has been associated with normalization of high pulmonary vascular resistance in adult patients. 195,196 As experience in mechanical ventricular assist devices increases in pediatric heart failure, 197,198 their use and the use of pulmonary vasodilators will likely redefine what truly constitutes fixed, irreversible elevation of pulmonary vascular resistance that would preclude orthotopic heart transplantation in pediatric heart disease.…”

Role of paediatric assist device in bridge to transplant

“…It may be assumed that continuous unloading of the LV, which thereby lowers left atrial pressure, is the theoretical basis for VAD implantation in these patients to improve their pulmonary hypertension. This theory has been substantiated in adult patients (49). High pulmonary vascular resistance seems to be amenable to significant improvement with the help of VAD support for the failing LV.…”

Post-transplant survival after lowering fixed pulmonary hypertension using left ventricular assist devices

“…The efficacy of left ventricular assist devices in lowering fixed pulmonary hypertension has been extensively documented by us and others in the past and is evolving as an accepted treatment strategy [4][5][6][7]. However, the long-term post-transplant outcome of this approach has not yet been compared to that of orthotopic cardiac transplantation in patients without pulmonary hypertension.…”

“…Treatment options for cardiac transplant candidates with fixed pulmonary hypertension include reversal of pulmonary hypertension prior to cardiac transplantation using left ventricular assist devices and orthotopic cardiac transplantation [4][5][6][7][8][9]3].…”

“…Heterotopic cardiac transplantation and reversing of fixed pulmonary hypertension using ventricular assist devices prior to cardiac transplantation have been reported to be successful treatment options in these patients [3][4][5][6][7]. However, heterotopic cardiac transplantation is associated with a variety of adverse effects in the long run (arrhythmias, thromboembolism) [3,8,9].…”