Elena C. Holmes

Management of acute cardiac failure with mechanical assist: experience with the ABIOMED BVS 5000

BACKGROUND Mechanical circulatory assist industries have developed ventricular assist devices (VAD) for short-, intermediate-, and long-term use. The purpose of this report is to describe the progress made with the ABIOMED Biventricular System (BVS) 5000 (ABIOMED, Inc, Danvers, MA) short-term VAD. METHODS From June 1994 through August 2000, all cardiogenic shock patients who required short-term mechanical assist were supported with the ABIOMED BVS 5000. Insertion criteria included any condition that may potentially result in cardiac recovery. A formal algorithm for timing of insertion was established to standardize implantation criteria. RESULTS A total of 45 patients were supported at Hahnemann University Hospital, Philadelphia, PA. There were 26 male and 19 female patients, with a mean age of 57.9 years (range 33 to 80 years). Devices were inserted for postcardiotomy shock in 36 patients (80%) and precardiotomy shock in 9 patients (20%). The average duration of support was 8.3 days (range 1 to 31 days). Overall, there were 22 (49%) patients weaned from support and 14 (31%) discharged from the hospital. For patients in whom the device was implanted in accordance with an established protocol (group A), the wean and discharge rates were 60% and 43%, respectively. The most common morbidities included bleeding and adverse neurologic events. CONCLUSIONS The ABIOMED BVS 5000 VAD continues to be a valuable form of short-term mechanical assist for acute cardiogenic shock. The formation of a uniform VAD insertion algorithm has helped to standardize protocols in management.

Pharmacological Criteria for Ventricular Assist Device Insertion Following Postcardiotomy Shock: Experience with the Abiomed BVS System

Background/Aim:The traditional approach to postcardiotomy shock includes inotropic support followed by the application of an intra‐aortic balloon pump (IABP). Consideration toward insertion of a ventricular assist device (VAD) becomes necessary when these maneuvers fail to restore hemodynamic stability. The definition of maximal inotropic support, however, is lacking such that a standard formula for VAD insertion remains problematic. The purpose of this paper is to define the pharmacological thresholds for VAD implantation in the setting of postcardiotomy cardiogenic shock. Methods: The medical records of all adult open‐heart operations performed at Hahnemann University Hospital, Philadelphia, PA, from 1 July 1996 through 1 July 1999 were reviewed. Specific data were collected on the hernodynamics and inotrope levels upon separation from cardiopulmonary bypass (CPB). The hospital course was reviewed with attention toward documenting hospital mortality. Cardiogenic shock was defined as systolic blood pressure (SBP) < 100 mmHg, mean pulmonary artery blood pressure (mPAP) > 25 mmHg, central venous pressure (CVP) > 15 mmHg, and cardiac index (CI) < 2.0 L/min/per m2. lnotrope dosages were defined as low, moderate, and high according to assigned values.* A formula for VAD insertion was established if cardiogenic shock parameters were present in the setting of two or more high dose inotropes. Early VAD insertion was defined as implantation within three hours of the first attempt to wean from CPB. The VAD recipients were divided into two groups. Group A were VADs placed in conjunction with the formula. Group B was VADs placed in violation (excess) of the formula. The results of these two groups were compared.

Outpatient management of long-term assist devices

Current VAD technology has enabled patients to be safely discharged from hospital, awaiting transplantation in the setting of their home. The results of recent studies have proven that patients on LVADs as destination therapy fare better than their medical counterparts and enjoy a higher quality of life. The lessons learned thus far in the outpatient management of LVADs has convinced the medical and non-medical communities that this form of therapy is more than feasible in addressing the epidemic of heart failure. Newer devices are on the horizon. It is inevitable that more patients will be visible in the streets and workplace as the modifications in size and application become more user friendly. It will be our responsibility, as the guardians of this technology, to use it wisely and provide the support that is necessary for this special population of people.

The Thoratec Implantable Ventricular Assist Device (IVAD): Initial Clinical Experience

BACKGROUND The Thoratec Implantable Ventricular Assist Device (IVAD) is the only FDA-approved intracorporeal biventricular cardiac assist device. It is a titanium-coated version of its predecessor, the Paracorporeal Ventricular Assist Device (PVAD). The blood pump is compatible with the portable TLC-II driver, making home discharge feasible. METHODS Nine consecutive patients were implanted with the IVAD from June 2005 through March 2006. The indications for support were acute heart failure in 6 cases and chronic heart failure in 3 cases. All patients were managed with maximal medical therapies including intravenous inotropic drugs prior to implant. RESULTS All patients survived the surgical implant. Six patients were considered successful: 3 patients discharged to home and subsequently received transplantation, 2 are awaiting transplantation (1 at home and 1 in-house), and 1 patient was successfully explanted. Three patients expired postoperatively because of multiple organ system failure (2 patients) and pulmonary hemorrhage (1 patient). There were no device malfunctions. There was 1 localized driveline site infection and 1 thromboembolic event with partial visual loss. CONCLUSIONS The IVAD is a unique device capable of providing uni- or bi-ventricular support for either acute or chronic heart failure conditions. Its versatility permits bridge to transplant or recovery options. Home discharge is feasible.

Complications following Placement or Extraction of Endovascular Pacemaker and Defibrillator Leads— Cardiothoracic Surgical Intervention: Case Reports

Complications related to the insertion or removal of permanent pacemakers and implantable cardiac defibrillators are rare events. However, when adverse events occur, their severity may be life threatening. Rapid recognition of a problem followed by prompt consultation with a cardiothoracic surgeon is necessary to stabilize potentially catastrophic events. The immediate availability of surgical instruments as well as a formalized algorithm for management is necessary to control hemorrhagic situations. Four case reports illustrate these points.

Transmyocardial laser revascularization as sole reoperative therapy following late anginal recurrence: case report.

A case of recurrent angina 3 years following sole therapy transmyocardial laser revascularization (TMR) is described. Repeat sole therapy TMR with the Holmium:YAG system was performed and resulted in complete and immediate angina relief. Repeat TMR should be considered in patients with angina recurrence who underwent primary TMR.