Total ventricular assist for long-term treatment of heart failure

First Biventricular Jarvik 2000 Implants (Retroauricular Version) Via a Median Sternotomy

OBJECTIVES

Organ shortages and increased numbers of nontransplant older patients have necessitated a search for alternatives to heart transplants. The Jarvik 2000 assist device (Jarvik Heart, Inc., Manhattan, NY, USA), as a small long-term axial flow pump, offers many advantages, such as retroauricular power supply, which minimizes driveline infection risks. When implanted biventricularly, the device may offer support for patients with biventricular heart failure, especially for nontransplant patients as a destination therapy.

MATERIALS AND METHODS

We implanted biventricular Jarvik 2000 systems into 3 men (aged, 65.3 ± 5.0 y; ejection fraction, 24.7% ± 1.5% for left ventricle and 17.7% ± 5.0% for right ventricle). These were the first patients worldwide to receive a biventricular Jarvik 2000 device with retroauricular power supply via a median sternotomy and with additional cardiac surgical procedures.

RESULTS

No technical problems were noted during biventricular assist device implant. Mean support time on the device was 224 ± 198 days. All 3 patients showed sufficient cardiac support; 2 patients died from noncardiac complications. Patient 1 died on day 3 as a result of postoperative hepatic failure after preoperative reanimation, and patient 3 died as a result of an ileus and colon perforation after 50 days. Patient 2 died of ventricular fibrillation (after 1.5 y), which occurred 1 year after right ventricular pump shutdown, although significant improvement of right ventricle function was shown (ejection fraction increased by 48%).

CONCLUSIONS

Our 3 patients were old, had multiple comorbidities, and needed further cardiac surgery. None of the patients died as a result of technical failure of the device but because of complications accompanying their morbidities. If complication rates can be reduced, a biventricular assist device implant could and should be considered as a potential alternative for nontransplant patients.

Mechanical assistance of the circulation during cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock still has a grave prognosis. We present the recent advances in mechanical circulatory support (MCS) for the treatment of refractory cardiogenic shock.

RECENT FINDINGS

The contraindications for short-term MCS in rapid-onset cardiogenic shock are becoming fewer and the threshold for its application has been progressively lowered. Short-term MCS is increasingly used in refractory cardiac arrest and will be probably integrated as the last means in the advanced cardiopulmonary resuscitation algorithm (provided there is experienced team and technical support). Improved device technology has contributed to improved results of long-term MCS. Emergent application of long-term MCS in patients with critical cardiogenic shock after a long history of progressively deteriorating end-stage chronic heart failure should be interpreted as delayed application associated with increased mortality.

SUMMARY

Although MCS can be life saving in cardiogenic shock, the results are still suboptimal. Mortality is associated with the critical presupport state and the adverse events during MCS. Early initiation of support that meets the patient's requirements, potent support in the early phase, adverse event prevention, global combined management (surgical, interventional, medical), balanced support duration, bridging to further therapeutic modalities including heart transplantation or longer-term support, and advanced technology could offer improved results.