Left Ventricular Assist Devices – The New Zealand Experience

Critical Care, 2011

Introduction Peripartum cardiomyopathy (PPCM) patients refractory to medical therapy and intra-aortic balloon pump (IABP) counterpulsation or in whom weaning from these therapies is impossible, are candidates for a left ventricular assist device (LVAD) as a bridge to recovery or transplant. Continuous-flow LVADs are smaller, have a better long-term durability and are associated with better outcomes. Extra corporeal membrane oxygenation (ECMO) can be used as a temporary support in patients with refractory cardiogenic shock. The aim of this study was to evaluate the efficacy and safety of mechanical support in acute and critically ill PPCM patients. Methods This was a retrospective search of the patient database of the Ghent University hospital (2000 to 2010). Results Six PPCM-patients were treated with mechanical support. Three patients presented in the postpartum period and three patients at the end of pregnancy. All were treated with IABP, the duration of IABP support ranged from 1 to 13 days. An ECMO was inserted in one patient who presented with cardiogenic shock, multiple organ dysfunction syndrome and a stillborn baby. Two patients showed partial recovery and could be weaned off the IABP. Four patients were implanted with a continuous-flow LVAD (HeartMate II®, Thoratec Inc.), including the ECMO-patient. Three LVAD patients were successfully transplanted 78, 126 and 360 days after LVAD implant; one patient is still on the transplant waiting list. We observed one peripheral thrombotic complication due to IABP and five early bleeding complications in three LVAD patients. One patient died suddenly two years after transplantation. Conclusions In PPCM with refractory heart failure IABP was safe and efficient as a bridge to recovery or as a bridge to LVAD. ECMO provided temporary support as a bridge to LVAD, while the newer continuous-flow LVADs offered a safe bridge to transplant.

Journal of Cardiac Surgery, 2008

Purpose: The use of ventricular assist devices (VADs) in patients with chronic end-stage or acute heart failure has led to improved survival. We present our experience since 1987. Subjects and Methods: Between July 1987 and December 2006, 1026 VADs were implanted in 970 patients. Most of them were men (81.9%). The indications were: cardiomyopathy (n = 708), postcardiotomy heart failure (n = 173), acute myocardial infarction (n = 36), acute graft failure (n = 45), a VAD problem (n = 6), and others (n = 2). Mean age was 46.1 (range 3 days to 78) years. In 50.5% of the patients the VAD implanted was left ventricular, in 47.9% biventricular, and in 1.5% right ventricular. There were 14 different types of VAD. A total artificial heart was implanted in 14 patients. Results: Survival analysis showed higher early mortality (p < 0.05) in the postcardiotomy group (50.9%) than in patients with preoperative profound cardiogenic shock (31.1%) and patients with preoperative end-stage heart failure without severe shock (28.9%). A total of 270 patients were successfully bridged to heart transplantation (HTx). There were no significant differences in long-term survival after HTx among patients with and without previous VAD. In 76 patients the device could be explanted after myocardial recovery. In 72 patients the aim of implantation was permanent support. During the study period 114 patients were discharged home. Currently, 54 patients are on a device. Conclusions: VAD implantation may lead to recovery from secondary organ failure. Patients should be considered for VAD implantation before profound, possibly irreversible, cardiogenic shock occurs. In patients with postcardiotomy heart failure, a more efficient algorithm should be developed to improve survival. With increased experience, more VAD patients can participate in out-patient programs.

The Journal of Heart and Lung Transplantation, 2005

The Journal of Heart and Lung Transplantation, 2011

The Annals of Thoracic Surgery, 2013

Background. The HeartWare ventricular assist device (HVAD) system (HeartWare International Inc, Framingham, MA) is a new centrifugal continuous-flow ventricular assist device. The aim of the present study is to review our institutional experience with this novel device. Methods. We reviewed the files of 50 patients (39 men, 11 women) with a mean age of 50.6 ؎ 11.8 years (range, 19 to 70 years) who underwent HVAD implantation between July 2009 and November 2011. Two patients underwent HeartWare BIVAD implantation. The underlying heart diseases were end-stage ischemic heart disease (n ‫؍‬ 12), acute myocardial infarction (n ‫؍‬ 9), dilated cardiomyopathy (n ‫؍‬ 27) and acute myocarditis (n ‫؍‬ 2). Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles were level 1 (n ‫؍‬ 11), 2 (n ‫؍‬ 5), 3 (n ‫؍‬ 10), and 4 (n ‫؍‬ 24). Results. After a cumulative support duration of 11,086 days, Kaplan-Meier analysis revealed a survival of 82.0%, 77.9%, 75.5%, at 1, 12, and 24 months, respectively. Causes of early death were right heart failure (n ‫؍‬ 4), multiorgan failure (n ‫؍‬ 2), septic shock (n ‫؍‬ 2), and major neurologic complications (n ‫؍‬ 4). One late death occurred due to a right heart failure. Comparison between patients operated on in cardiogenic shock (INTERMACS 1 and 2) and patients who underwent elective HVAD implantation (INTERMACS 3 and 4) revealed a survival of 61.5% and 44.1% for the INTERMACS 1 and 2 group and 90.3% and 87.1% for the INTERMACS 3 and 4 group at 1 and 12 months, respectively (odds ratio, 4.67; p ‫؍‬ 0.003). One patient was weaned from the system after 2 years. Eleven patients (22%) were successfully bridged to transplantation. Mean time to transplantation was 209 days (range, 72 to 427 days). Posttransplant survival at the 1-year follow-up was 90.9% (11 patients). Conclusions. Our experience with HVAD shows satisfying results with an excellent posttransplantation survival. Moreover, the stratified survival based on the level of preoperative stability shows better outcomes in patients undergoing elective HVAD implantation.

The Journal of Heart and Lung Transplantation, 2008

Background: For patients with persistent cardiogenic shock refractory to intraaortic balloon pump (IABP) support, there are only limited means of resuscitation and bridging to surgical left ventricular assist device (LVAD) implantation. Extracorporeal membrane oxygenation and emergency surgical approaches have been attempted but are associated with significant morbidity and mortality. We evaluated the efficacy of a percutaneous left ventricular assist device (PVAD) as a bridge to LVAD implantation in patients in cardiogenic shock refractory to IABP and pressor support. Methods: Between May 2003 and April 2006, at our institution, 18 patients in severe refractory cardiogenic shock received a PVAD as a bridge to LVAD placement or orthotopic heart transplantation. Six patients had ischemic cardiomyopathy, and 12 had nonischemic cardiomyopathy. At the time of PVAD placement, 17 were receiving IABP support, and 10 were undergoing cardiopulmonary resuscitation. Results: The mean duration of PVAD support was 4.2 Ϯ 2.5 days. During this time, the cardiac index improved from 0.86 Ϯ 0.66 to 2.50 Ϯ 0.93 liters/min/m 2 (p Ͻ 0.001), systolic blood pressure improved from 72 Ϯ 11 to 98 Ϯ 15 mm Hg (p ϭ 0.001), and systemic mixed venous oxygenation improved from 37 Ϯ 7 to 62 Ϯ 6 mm Hg (p Ͻ 0.001). We terminated life support in 4 of the 18 patients before LVAD placement; 14 were successfully bridged to LVAD or heart transplantation. The mortality rate was 27% at 30 days and 33% at 6 months. There were no PVAD-associated deaths. Conclusion: In patients with terminal hemodynamic collapse, PVAD support is an effective bridging therapy to LVAD and appears to be a viable alternative to other invasive methods of support.

The Journal of Thoracic and Cardiovascular Surgery, 2003

Patients in acute cardiogenic shock may require placement of left ventricular assist devices before undergoing standard pretransplant evaluations. This practice raises ethical and logistic concerns and has led us to investigate the shortand long-term outcomes for this patient population.

Journal of cardiology, 2014

Two implantable continuous-flow left ventricular assist devices (LVADs), DuraHeart (Terumo Heart, Ann Arbor, MI, USA) and EVAHEART (Sun Medical, Nagano, Japan), were approved in Japan in April 2011. We analyzed the midterm outcome of patients implanted with these implantable LVADs at the University of Tokyo Hospital. A total of 31 patients who underwent implantation of LVADs (10 DuraHeart, 21 EVAHEART) as a bridge to transplantation at our institution between April 2011 and August 2013 were retrospectively reviewed. All patients were followed up through December 2013. Seven patients underwent conversions from NIPRO paracorporeal LVAD (Nipro, Osaka, Japan) to an implantable LVAD. The mean observation period was 483±239 days (41.0 patient years). Eight patients were transplanted and one patient showed functional recovery with subsequent LVAD explantation. Four patients died due to cerebrovascular accident, empyema, or device malfunction due to pump thrombosis after cerebral bleeding. ...

European Heart Journal Supplements, 2004

Objective The increasing number of patients awaiting heart transplant and the shortage of donors led to the development of a variety of left ventricular assist devices (LVAD). We analyse our experience in order to evaluate the efficacy of LVAD as bridge to transplant and the feasibility of permanent implantation. Patients The data are drawn from our experience on 50 patients, implanted with the Novacor LVAD and from a limited series of 4 patients implanted with a Lion Heart totally implantable permanent LVAD. Results Seventeen patients died on the device, 32 underwent heart transplant (9 died after transplant) and one is still on device. The causes of death were mostly related to cerebrovascular events or multi-organ failure. Cardiac output, wedge pressure, pulmonary vascular resistance and mean pulmonary pressure improved significantly. Cerebrovascular complications occurred mostly during the first 3 months of assistance, whereas the incidence of infections remained constant during the follow-up period. With a mean time of assistance of 211 days, we had only two cases of device malfunction. The four Lion-Heart patients experienced a clear improvement in hemodynamics but at a price of a significant complication rate. Three of them died after 418, 105 and 380 days of assistance. Device malfunction was observed in two cases. Conclusions LVAD Novacor has shown good hemodynamic improvement and reliable mechanical performance and long-term bridging can be considered fairly safe since most complications seem to occur within the first 90 days. Destination therapy with totally implantable devices seems to need further engineering and technical development.