L. Kizner

Novacor left ventricular assist system versus heartmate vented electric left ventricular assist system as a long-term mechanical circulatory support device in bridging patients: A prospective study

OBJECTIVE Long-term mechanical circulatory support as a bridge-to-transplantation procedure and bridge to recovery is of increasing importance. The implantable left ventricular assist devices, Novacor N100 left ventricular assist system (Baxter Healthcare Corporation, Berkeley, Calif) and TCI HeartMate vented electric left ventricular assist system (Thermo Cardiosystems Inc, Woburn, Mass), have proved to be efficient devices in bridge-to-transplantation settings and for prolonged support. The two systems were compared with regard to reliability and morbidity. METHODS Between October 1996 and March 1998, a prospective, single-center study was done that included 40 patients, 20 of whom were treated with the Novacor system and 20 of whom were treated with the HeartMate device. The diseases were mainly dilated cardiomyopathy (13/9) and ischemic cardiomyopathy (6/10). There were no statistically significant differences between the two groups regarding age, sex, preoperative clinical blood chemistry values, hemodynamic data, or risk factors. RESULTS There were no statistically significant differences between the two groups with regard to postoperative hemodynamics, organ recovery, out-of-hospital support, and survival to heart transplantation. Mean duration of support was 235.3 +/- 210 days for the Novacor group and 174.6 +/- 175 days for the HeartMate group and mean out-of-hospital support was 241 +/- 179 days and 166 +/- 152 days for the two groups, respectively. Neurologic complications occurred significantly more often among the Novacor group, whereas the HeartMate group had a higher prevalence of infections and technical problems, which was statistically significant. Survival to transplantation was 65% for the Novacor group and 60% for the HeartMate group. CONCLUSIONS Most patients had organ recovery with left ventricular assist system support, and a considerable number of patients in both groups underwent transplantation. However, both devices need revision to address the current problems, that is, thromboembolism for the Novacor device and infection and reliability for the HeartMate device.

Single-center experience with the thoratec ventricular assist device☆☆☆

OBJECTIVE The Thoratec ventricular assist device (Thoratec Laboratories, Pleasanton, Calif) is widely accepted for univentricular and biventricular support in patients with various indications. The aim of this study is to describe our experience with implantation of the Thoratec ventricular assist device in more than 100 patients. METHODS From March 1992 to June 1998, 114 patients (98 men and 16 women; mean age, 47.9 years) received the Thoratec ventricular assist device for a mean duration of 44.9 days. The patients were divided into 3 groups. Group 1 included 84 patients in whom the system was applied as a bridge-to-transplant procedure. Group 2 included 17 patients with postcardiotomy cardiogenic shock, and group 3 included 13 patients with cardiogenic shock of other causes. RESULTS Sixty-eight percent of patients in group 1 survived to transplantation with a posttransplant survival of 88%. The only independent risk factor affecting survival was age more than 60 years. Survivals in groups 2 and 3 were 47% and 31%, respectively. Main complications in all groups were bleeding, multiple organ failure, liver failure, sepsis, and neurologic disorders. CONCLUSIONS The Thoratec ventricular assist device has proved to be a reliable device for bridge to transplantation and postcardiotomy support. Further studies are required on patient selection and on patient and device management to reduce the incidence of complications in these patient populations.

Bilateral antegrade perfusion of the superficial femoral artery to prevent limb ischaemia during combined use of Impella CP left ventricular assist device and extracorporeal life support

The combined use of extracorporeal cardiac life support and the Impella left ventricular assist device is feasible in severe cardiogenic shock. Ischaemic complications due to the arterial cannulation may occur. The following cases show how the use of a perfusion adapter for bilateral antegrade leg perfusion prevents malperfusion of the lower extremities.

Molecular adsorbent recirculating system technique for liver failure due to cardiogenic shock.

BACKGROUND Systematic data on clinical outcome in patients with liver failure due to cardiogenic shock are scarce. METHODS We performed a monocentric retrospective data analysis in 197 cardiogenic shock patients with serum bilirubin levels above 102 µmol/L receiving molecular adsorbent recirculating system (MARS). We assessed clinical outcome, recorded laboratory parameters, and tried to assess risk factors for survival. RESULTS The median duration of MARS was 87 hours (range, 20-315 hours) during a median time period of 9 days (range, 3-736 days). During MARS, 48 to 75% of patients developed infections and gastrointestinal, respiratory, and neurological complications, respectively. Inhospital mortality was 66% (n = 129). Baseline bilirubin levels were comparable between survivors and non-survivors. During MARS, bilirubin values decreased significantly in survivors but not in non-survivors. Of various clinical and biochemical parameters assessed at baseline, the sepsis-related Organ Failure Assessment score remained the only independent predictor of inhospital mortality. CONCLUSION Inhospital mortality is still unsatisfyingly high in cardiogenic shock patients with liver failure. Future studies should clarify whether MARS can definitively improve survival in these patients.

Transport von Patienten im schweren kardiogenen Schock unter Anwendung der mechanischen Kreislaufunterstützung: Patientenselektion und Vorgehensweise

ZusammenfassungGrundproblematik Patienten, die sich im therapierefraktären kardiogenen Schock befinden, sind auf eine intensive Versorgung angewiesen, die die Möglichkeiten eines normalen Krankenhauses häufig übersteigt. Der Transport dieser Patienten zur Weiterbehandlung in entsprechende Zentren ist jedoch nur mit erweiterten Unterstützungsmaßnahmen möglich. Wir stellten ein Team für die mobile mechanische Kreislaufunterstützung zusammen, mit dessen Hilfe selektierte Patienten in unser Zentrum zur Weiterbehandlung transportiert wurden. Patienten und Methodik Von 1993 bis 1997 wurden 46 hämodynamisch instabile Patienten im kardiogenen Schock nach sorgfältiger Evaluierung in unsere Klinik transportiert. Bei 16 von ihnen wurde als erweiterte Unterstützungsmaßnahme ein perkutaner femoro-femoraler kardiopulmonaler Bypass eingesetzt. Der Transport erfolgte mit dem Hubschrauber oder dem Intensivmobil. Ergebnisse Alle Patienten konnten ohne Zwischenfälle in unsere Klinik transportiert werden. Die Weiterbehandlung bestand in einer Fortsetzung der mechanischen Kreislaufunterstützung, z.T. mit Systemwechsel für die Langzeitunterstützung, einer PTCA, einer Bypass-Operation oder einer Herztransplantation. Insgesamt überlebten 7 der 16 Patienten (43%). Folgerungen In Anbetracht der aussichtslosen Situation der Patienten vor dem Transport lag die Überlebensrate bei fast 50%, wodurch der immense finanzielle und personelle Aufwand gerechtfertigt wird. Jedoch sollte diese Maßnahme auf jüngere Patienten beschränkt sein, bei denen eine Organerholung eher zu erwarten ist.SummaryBackground Patients with cardiogenic shock refractory to pharmacological therapy have to undergo specific therapeutic procedures which often are not available in a general hospital. The transport of these patients to specialized centers can only be performed using extended circulatory support measures. We established a mobile mechanical circulatory support team responsible for the transport of selected patients to our center for further therapy. Patients and methods Between 1993 and 1997, 46 hemodynamically unstable patients in cardiogenic shock were transported to our center following thorough evaluation. Sixteen of them received a percutaneous femoro-femoral cardiopulmonary bypass. Transport was performed by means of a helicopter or a special ambulance. Results All patients were successfully transported to our center. Further therapy consisted of a continuation of mechanical circulatory support partly using a different system for long term assistance; other patients underwent PTCA, coronary artery bypass grafting or heart transplantation. Seven out of 16 patients (43%) survived to be discharged from the hospital. Conclusions In view of the disastrous condition of the patients prior to transport, the survival rate of almost 50% justifies the employment of immense financial and staff resources. However, the procedure should be restricted to younger patients in whom organ recovery is more likely.