Discordance between cardiopulmonary physiology and physical therapy. Toward a rational basis for practice

Metabolic and ventilatory changes during postural change from the supine position to the reclining position in bedridden older patients

The prevention of pneumonia in bedridden older patients is important, and its recurrence in these patients is a relevant issue. Patients who are bedridden and inactive, and have dysphagia are considered to be at risk for pneumonia. Efforts to reduce the bedridden state and low activity may be necessary to reduce the risk of developing pneumonia in bedridden older patients. This study aimed to clarify the effects of postural change from the supine position to the reclining position on metabolic and ventilatory parameters and on safety in bedridden older patients. Using a breath gas analyzer and other tools, we assessed the following 3 positions: lying on the back (supine), resting in the Fowler position (Fowler), and resting in an 80° recline wheelchair (80°). Measurements were oxygen uptake, carbon dioxide output, gas exchange ratio, tidal volume (VT), minute volume, respiratory rate, inspiratory time, expiratory time, total respiratory time, mean inspiratory flow, metabolic equivalents, end-expiratory oxygen, and end-expiratory carbon dioxide as well as various vital signs. The study analysis included 19 bedridden participants. The change in oxygen uptake driven by changing the posture from the supine position to the Fowler position was as small as 10.8 mL/minute. VT significantly increased from the supine position (398.4 ± 111.2 mL) to the Fowler position (426.9 ± 106.8 mL) (P  = .037) and then showed a decreasing trend in the 80° position (416.8 ± 92.5 mL). For bedridden older patients, sitting in a wheelchair is a very low-impact physical activity, similar to that in normal people. The VT of bedridden older patients was maximal in the Fowler position, and the ventilatory volume did not increase with an increasing reclining angle, unlike that in normal people. These findings suggest that appropriate reclining postures in clinical situations can promote an increase in the ventilatory rate in bedridden older patients.

Management of early mobilization in intensive care units: a multicenter cross-sectional study

Objective

The aim of this study was to assess the management of early mobilization (EM) in Chinese intensive care units (ICUs).

Methods

This survey used a cross-sectional, observational design. A total of 65 tertiary and secondary hospitals were enrolled by convenience sampling and investigated using self-designed questionnaires.

Results

We identified 69 ICUs in Jiangsu, China (response rate: 94.2%). 74.2% (1,004/1,353) of the nurses and nursing managers from 65 ICUs reported mobility practice. For the mobility level, 98.1% (1,327) reported use of in-bed exercise, 5.7% (77) sitting on a side of bed, 21.7% (294) transfer to chair, and 2.4% (33) walking. The most frequently reported barriers to early mobility were unplanned extubation, nursing resource, and absence of physical therapist. Nurses’ educational backgrounds, nursing experience, the lack of nursing resources, absence of physician, and the weakness of patient were the factors that influenced ICU early rehabilitation (P<0.01).

Conclusions

Although implementation rates for EM in critically ill patients are high, the activity level is generally poor in most of the involved ICUs.

Cardiac performance is influenced by rotational changes of position in the transversal plane, both in the horizontal and in the 60̊ head-up postures

BACKGROUND

Echocardiography is usually performed with the subject/patient lying in the left lateral position (LLP), because the acoustic window is better in this than in the supine position (SP). The aim was to investigate cardiac responses to rotational changes of position in the transversal plane, from SP to LLP while horizontal, and from leaning on the back (HUT-LB) to leaning on the left side (HUT-LL) while tilted 60° head-up from the horizontal.

METHODS

Healthy men (n = 12) underwent 10-min HUT provocations. Cardiac variables were measured using two-dimensional echocardiography, Doppler, tissue Doppler imaging and arterial pressures using a volume-clamp method.

RESULTS

In horizontal posture, cardiac volumes were smaller in SP than in LLP: end-diastolic volume (EDV) by 14%, end-systolic volume (ESV) by 13%, stroke volume (SV) by 14%, and cardiac output (CO) by 16% (P<0·03). In addition, the mitral annular plane systolic excursion (MAPSE) was 11% smaller (P = 0·001) and the left ventricle isovolumic relaxation time (IVRT) 27% longer in SP than in LLP. The ejection fraction, heart rate, arterial pressure and pulmonary ventilation were similar in SP and LLP. During HUT, EDV, SV, CO and MAPSE were smaller, and IVRT was longer, in HUT-LB than in HUT-LL, by -19%, -20%, -17%, -18% and +35%, respectively (P<0·04).

CONCLUSIONS

Cardiac performance is enhanced in LLP versus SP and in HUT-LL versus HUT-LB, which can be attributed to improved venous return, conceivably, wholly or in part, due to increased hydrostatic pressure gradients between the caval veins and the heart in the LLP and HUT-LL positions.

Efficacy of early passive tilting in minimizing ICU-acquired weakness: A randomized controlled trial

Purpose

To investigate whether passive tilting added to a standardized rehabilitation therapy improved strength at Intensive Care Unit (ICU) discharge.

Material and methods

This single-center trial included patients admitted to an adult surgical ICU and ventilated for at least 3 days. Patients were randomized to daily standardized rehabilitation therapy alone or with tilting on a table for at least 1 h. The primary outcome was the Medical Research Council (MRC) sum score at ICU discharge. Muscular recovery was a secondary outcome.

Results

Of 145 included patients, 125 received mobilization, 65 in the Tilt group and 60 in the Control group. Total mobilization duration (median [25th–75th percentiles]) in the Tilt group was 1020 [580–1695] versus 1340 [536–2775] minutes in the Control group (p = 0.313). MRC sum scores at ICU discharge were not significantly different between groups (Tilt, 50 [45–56] versus 48 [45–54]; p = 0.555). However, the number of patients with weakness was higher in the Tilt group at baseline (Tilt: 60/65 versus 48/60, p = 0.045) and muscular recovery was better in the Tilt group (p = 0.004).

Conclusions

Passive tilting added to a standardized rehabilitation therapy did not improve muscle strength at ICU discharge in surgical patients even if a faster recovery with tilting is suggested.

Immediate Effects of Acapella® on Dynamic Lung Compliance in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome: A Case Series

Background and Aims:

One potential complication of acute respiratory distress syndrome (ARDS) is reduced dynamic compliance, saturation for peripheral oxygenation (SpO₂) and increased sputum in patients that are mechanically ventilated. Airway clearance technique is the treatment given for patients on mechanically ventilator with ARDS. The purpose of the case series is to know the immediate effects of Acapella® on dynamic lung compliance (Cdyn) in subject with ARDS.

Subjects and Methods:

Patients who are on ventilator for more than 48hrs were included in the study. Readings for Cdyn, SpO₂ were noted at baseline, immediately post treatment, 10, 20, 30 and 60minutes. Pre and post treatment sputum volume was also noted.

Results:

Five patients were included with age range of 25 to 75 years. Clinical improvement was seen immediately after treatment in Cdyn and SpO₂. There was not much change in sputum volume.

Conclusion:

Acapella^® increased the dynamic compliance of lungs and sputum clearance in mechanically ventilated ARDS patients.

Personalising airway clearance in chronic lung disease

This review describes a framework for providing a personalised approach to selecting the most appropriate airway clearance technique (ACT) for each patient. It is based on a synthesis of the physiological evidence that supports the modulation of ventilation and expiratory airflow as a means of assisting airway clearance. Possession of a strong understanding of the physiological basis for ACTs will enable clinicians to decide which ACT best aligns with the individual patient's pathology in diseases with anatomical bronchiectasis and mucus hypersecretion.The physiological underpinning of postural drainage is that by placing a patient in various positions, gravity enhances mobilisation of secretions. Newer ACTs are based on two other physiological premises: the ability to ventilate behind obstructed regions of the lung and the capacity to achieve the minimum expiratory airflow bias necessary to mobilise secretions. After reviewing each ACT to determine if it utilises both ventilation and expiratory flow, these physiological concepts are assessed against the clinical evidence to provide a mechanism for the effectiveness of each ACT. This article provides the clinical rationale necessary to determine the most appropriate ACT for each patient, thereby improving care.

The effect of positional changes on oxygenation in patients with head injury in the intensive care unit

Background:

Following head injury, cardiopulmonary functions are impaired and this disturbs the oxygenation transport pathway. Expanding cardiopulmonary physical therapy to encompass the oxygen transport system as a whole has implication for treatment as well as assessment and treatment outcome. Therefore, the aim of the study is to assess the oxygenation level in head injury patients with relation to body positioning in the intensive care unit (ICU).

Methodology:

Thirty consecutive patients with head injury with hemodynamically stable were included from the surgical ICU, ages ranging from 15 to 50 years. Noninvasive vital parameters (oxygen saturation [SpO₂], pulse rate [PR], respiratory rate [RR], and blood pressure [BP]) were observed and recorded in different body positions at regular intervals of 5 min for 15 min in each position.

Results:

There was increment in SpO₂ value in all positions from 0 min to end of 15 min in supine (98.63 ± 0.36–98.73 ± 0.30), right-side lying (98.77 ± 0.30–98.93 ± 0.20), left-side lying (98.73 ± 0.29–99.03 ± 0.24), and recline sitting (30°–70°) (99.03 ± 0.24–99.50 ± 0.22). However, there was statistically significant increment in recline sitting (30°–70°) compared to other positions (P = 0.036) while other parameters (PR, RR, and BP) were getting stabilized at lower values at end of 15 min in every positions tested.

Conclusion:

We conclude that upright position bring about significant increase in arterial SpO₂ compared to any other positions. Other vital parameters were seen to stabilize at lower values at the end of 15 min in every position tested.

A periodized model for exercise improves the intra-hospital evolution of patients after myocardial revascularization: a pilot randomized controlled trial

OBJECTIVE

To compare models of the postoperative hospital treatment phase after myocardial revascularization.

DESIGN

A pilot randomized controlled trial.

SETTING

Hospital patients in a hospital setting.

SUBJECTS

Thirty-two patients with indications for myocardial revascularization were included between January 2008 and December 2009, with a left ventricular ejection fraction (LVEF) ≥50%, 1-second forced expiratory volume (FEV(1)) ≥60 and forced vital capacity (FVC) ≥60% of predicted value.

INTERVENTIONS

Patients were randomly placed into two groups: one performed prescribed exercises according to the model proposed by the American College of Sports Medicine (ACSM) and the other according to a periodized model.

MAIN MEASURES

Partial pressure of O(2) (P o (2)) and arterial O(2) saturation (Sao (2)), percentage of predicted FVC and total distance on the six-minute walking test (6MWT).

RESULTS

Twenty-seven patients were re-evaluated upon release from the hospital (ACSM = 14 and PP = 13). Five patients extubated for more than 6 hours in the postoperative period were excluded from the sample. In the preoperative period the variables P o (2), Sao (2), % FVC and 6MWT were similar. In the postoperative period, a reduction was observed for all parameters in both groups. Upon comparison of the groups, a difference was observed in P o (2) (ACSM = 68.0 ± 4.3 vs. PP = 75.9 ± 4.8 mmHg; P < 0.001), Sao (2) (ACSM = 93.5 ± 1.4 vs. PP = 94.8 ± 1.2%; P = 0.018) and 6MWT (ACSM = 339.3 ± 41.7 vs. PP = 393.8 ± 25.7 m; P < 0.001). There was no difference in % FVC.

CONCLUSION

Patients after myocardial revascularization following a periodized model of exercise presented a better intra-hospital evolution when compared to those using the ACSM model.

Phase I of cardiac rehabilitation: A new challenge for evidence based physiotherapy

Cardiac rehabilitation protocols applied during the in-hospital phase (phase I) are subjective and their results are contested when evaluated considering what should be the three basic principles of exercise prescription: specificity, overload and reversibility. In this review, we focus on the problems associated with the models of exercise prescription applied at this early stage in-hospital and adopted today, especially the lack of clinical studies demonstrating its effectiveness. Moreover, we present the concept of "periodization" as a useful tool in the search for better results.

The effect of breath physiotherapeutic maneuvers on cerebral hemodynamics: a clinical trial

OBJECTIVE

To observe the repercussion of respiratory physiotherapy techniques on the mean arterial pressure (MBP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), jugular venous oxygen pressure (PjvO2) and jugular venous oxygen saturation (SjvO2).

METHOD

The sample consisted of 20 patients with head trauma. The protocol consisted of physiotherapy techniques application of vibrocompression (VBC), expiratory flow increase (EFI) and suction.

RESULTS

The results show the maintenance on variables of cerebral hemodynamics during the techniques of VBC and EFI. However, in relation to suction, there was an increase of MBP, ICP, with maintenance of CPP, PjvO2 and SjvO2 and return to baseline of MBP and ICP 10 minutes after the end of suction.

CONCLUSION

The respiratory physiotherapy techniques (VBC, EFI) do not promote cerebral hemodynamic repercussion, unlike suction, in severe head injury patients, mechanically ventilated, sedated and paralyzed.

Chest tube selection in cardiac and thoracic surgery: a survey of chest tube-related complications and their management

BACKGROUND

Blood accumulating inside chest cavities can lead to serious complications if it is not drained properly. Because life-threatening conditions can result from chest tube occlusion after thoracic surgery, large-bore tubes are generally employed to optimize patency.

AIMS

The aim of this study was to better define problems with current paradigms for chest drainage.

MATERIALS AND METHODS

A survey was conducted of North American cardiothoracic surgeons and specialty cardiac surgery nurses. A total of 108 surgeons and 108 nurses responded.

RESULTS

The survey revealed that clogging leading to chest-tube dysfunction is a major concern when choosing tube size. Of surgeons responding, 106 of 106 (100%) had observed chest tube clogging, and 93 of 106 (87%) reported adverse patient outcomes from a clogged tube. Despite techniques such as tube stripping, tapping, and squeezing, up to 51% of surveyed surgeons stated they are not satisfied with currently available tubes and procedures to avoid tube occlusion and some even forbid the stripping maneuver for fear of causing more bleeding by the negative pressures generated. In addition, respondents noted that patients experience increasing discomfort with increasing drain size.

DISCUSSION

The major reason surgeons choose large-diameter chest tubes is linked to concern about the suboptimal available methods to avoid and treat chest-tube clogging. Even though larger tubes are thought to be associated with more pain, physicians generally err on the side of caution to avoid clogging and insert tubes with larger diameters.

CONCLUSION

Results of this survey highlight the frequent problems with clogging with current postsurgical chest drainage systems and suggest the need for innovative solutions to avoid clogging complications and overcome clinician concern and patient pain.

Influence of pleural drainage on postoperative pain, vital capacity and six-minute walk test after pulmonary resection

OBJECTIVE

To evaluate the influence of pleural drainage on the distance covered on the six-minute walk test, pain intensity and vital capacity in patients submitted to pulmonary resection.

METHODS

Thirteen consecutive patients from the Thoracic Surgery Infirmary of Hospital São Paulo, Brazil, submitted to closed pleural drainage (0.5-in multiperforated chest tube) in the postoperative period following pulmonary resection (lobectomy, segmentectomy and pulmonary nodule resection) were evaluated. The decision for chest tube removal followed clinical criteria defined by the surgical team, who did not participate in the study. Vital capacity, pain intensity (using a visual analog pain scale) and the distance covered on the six-minute walk test were determined 30 min prior to and 30 min after the removal of the chest tube. The statistical analysis was performed using paired t-tests, and the level of significance was set at 0.05.

RESULTS

After the removal of the chest tube, the visual analog scale pain scores were significantly lower (3.46 cm vs. 1.77 cm; p = 0.001) and the distance covered on the six-minute walk test was significantly higher (374.34 m vs. 444.62 m; p = 0.03). Vital capacity prior to and after chest tube removal was not significantly affected (2.15 L and 2.25 L, respectively; p = 0.540).

CONCLUSIONS

The results of the present study suggest that the presence of a chest tube is a factor significantly associated with postoperative pain and functional limitation in patients submitted to pulmonary resection.

Early mobility and walking program for patients in intensive care units: creating a standard of care

New technologies in critical care and mechanical ventilation have led to long-term survival of critically ill patients. An early mobility and walking program was developed to provide guidelines for early mobility that would assist clinicians working in intensive care units, especially clinicians working with patients who are receiving mechanical ventilation. Prolonged stays in the intensive care unit and mechanical ventilation are associated with functional decline and increased morbidity, mortality, cost of care, and length of hospital stay. Implementation of an early mobility and walking program could have a beneficial effect on all of these factors. The program encompasses progressive mobilization and walking, with the progression based on a patient's functional capability and ability to tolerate the prescribed activity. The program is divided into 4 phases. Each phase includes guidelines on positioning, therapeutic exercises, transfers, walking reeducation, and duration and frequency of mobility sessions. Additionally, the criteria for progressing to the next phase are provided. Use of this program demands a collaborative effort among members of the multidisciplinary team in order to coordinate care for and provide safe mobilization of patients in the intensive care unit.

Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of the literature

Survivors of critical illness often undergo an extended recovery trajectory. Reduced functional ability is one of several adverse outcomes of prolonged bed rest and mechanical ventilation during critical illness. Skeletal muscle weakness is known to be one of the major phenomena that account for reduced functional ability. Although skeletal muscle weakness is evident after prolonged mechanical ventilation (PMV), few studies have tested the benefits of various types of mobility interventions in this population. The purpose of this article is to review the published research on improving mobility outcomes in patients undergoing PMV. For this review, published studies were retrieved from MEDLINE, PubMed, CINAHL, and the Cochrane Database of Systematic Reviews from January 1990 to July 2007. A total of 10 relevant articles were selected that examined the effect of whole body physical therapy, electrical stimulation (ES), arm exercise, and inspiratory muscle training (IMT). Overall, there is support for the ability of mobility interventions to improve outcomes in patients on PMV but limited evidence of how to best accomplish this goal. Generating more data from multicenter studies and randomized controlled trials is recommended.

Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients

The Task Force reviewed and discussed the available literature on the effectiveness of physiotherapy for acute and chronic critically ill adult patients. Evidence from randomized controlled trials or meta-analyses was limited and most of the recommendations were level C (evidence from uncontrolled or nonrandomized trials, or from observational studies) and D (expert opinion). However, the following evidence-based targets for physiotherapy were identified: deconditioning, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. Discrepancies and lack of data on the efficacy of physiotherapy in clinical trials support the need to identify guidelines for physiotherapy assessments, in particular to identify patient characteristics that enable treatments to be prescribed and modified on an individual basis. There is a need to standardize pathways for clinical decision-making and education, to define the professional profile of physiotherapists, and increase the awareness of the benefits of prevention and treatment of immobility and deconditioning for critically ill adult patients.

Role of physiotherapy in the management of chronic lung diseases: an overview of systematic reviews

Four Cochrane respiratory reviews of relevance to physiotherapeutic practice are discussed in this overview. Physiotherapists aim to improve ventilation for people with respiratory disease, and approach this using a variety of techniques. As such, the reviews chosen for discussion consider a wide range of interventions commonly used by physiotherapists: breathing exercises, bronchopulmonary hygiene techniques and physical training for peripheral and respiratory muscles. The reviews show that breathing exercises may have beneficial effects on health-related quality of life in asthma, and that inspiratory muscle training (IMT) may improve inspiratory muscle strength. However, the clinical relevance of increased respiratory muscle strength per se is unknown, and the longer-term effects of breathing exercises on morbidity have not been considered. One review clearly shows that bronchopulmonary hygiene techniques in chronic obstructive pulmonary disease (COPD) and bronchiectasis increase sputum production. Frequent exacerbation is associated with increased sputum and high bacterial load, suggesting that there may be important therapeutic benefit of improved sputum clearance. Future studies evaluating the long-term effects of bronchopulmonary hygiene techniques on morbidity are recommended. In the third review, the importance of pulmonary rehabilitation in the management of COPD is once again reinforced. Physiotherapists are crucial to the delivery of exercise training programmes, and it is likely that the effects of pulmonary rehabilitation extend to other important outcomes, such as hospital admission and re-admission. On the basis of the evidence provided by these Cochrane reviews, this overview highlights important practice points of relevance to physiotherapy, and recommendations for future studies.

A study of the facilitation of respiration in myotonic dystrophy

BACKGROUND AND PURPOSE

Dystrophia myotonica or myotonic dystrophy is a progressive neuromuscular disorder in which patients demonstrate an irregular respiratory pattern and are particularly subject to cardiopulmonary compromise. The aim of the present study was to investigate the effects of both proprioceptive neuromuscular facilitation (PNF) and staged basal expansion (SBE) breathing exercises in subjects with myotonic dystrophy in two different positions: high support sitting and left side-lying.

METHOD

A randomized, double-blind study design was used. Seven non-congenital myotonic dystrophy subjects took part in the study. Six 'treatment' levels were applied to each subject: resting in high support sitting; resting in left side-lying; PNF of deep breathing in high support sitting; PNF of deep breathing in left side-lying; SBE in high support sitting and SBE in left side-lying. The outcome measures employed were arterial oxygen saturation (SpO2) and heart rate, as measured by oximetry and thoraco-abdominal motion (TAM), and respiratory rate, as measured by a pneumograph.

RESULTS

The PNF technique was found to be the main contributor to improvement in SpO2 for subjects with myotonic dystrophy, where a 2.2% increase was found in the high support sitting position and a 2.6% increase was found in the left side-lying position. There was an increase of between 377% and 556% in TAM during application of both treatment techniques, in either the high support sitting or left side-lying positions. Respiratory rate declined between 15% and 30% immediately after treatment application and heart rate dropped slightly by between 0.2% and 4.1%.

CONCLUSION

The present study provides objective evidence that application of these respiratory physiotherapy interventions elicits an improvement in respiratory function in subjects with myotonic dystrophy. Further research into the physiological effects of these techniques could explore the mechanisms responsible for improvement in respiratory indices.

The effect of breathing exercises with body positioning on regional lung ventilation

This review discusses the distribution of ventilation in the normal adult lung and includes the influence of quiet and deep breathing on regional ventilation. The effects of breathing at low lung volumes; inspiratory flow rate; posture; age; and body weight on ventilation are also described. A selection of breathing exercises are examined with regard to their ability to influence regional ventilation. There is no evidence that breathing control (diaphragmatic breathing exercises) improves regional ventilation to the dependent zones of the lungs. Limited evidence does suggest that thoracic expansion exercises, whereby respiratory muscles are voluntarily contracted to alter regional chest wall expansion, can improve underlying ventilation. However, there remains a paucity of evidence regarding the effects of breathing exercises on regional ventilation.

The physiotherapy management of patients undergoing coronary artery surgery: A questionnaire survey

The current physiotherapy management of patients undergoing coronary artery surgery in 22 public and 13 private hospitals across Australia and New Zealand was examined using a questionnaire survey. Respondents were asked to identify assessment and treatment techniques used in the pre- and post-operative management. An 83 per cent response from physiotherapists was obtained. Ninety-four per cent of respondents reported that pre-operative assessment was performed routinely. Eighty-nine per cent of respondents indicated that all patients were treated routinely by physiotherapists in the post-extubation period. Positioning and deep breathing exercises were the most commonly used techniques for patients post-extubation. Factors determining treatment choice and the impact of research on current physiotherapy practice are discussed.

Effects of deep breathing exercise and ambulation on pattern of ventilation in post-operative patients

Deep breathing and ambulation are used by physiotherapists for patients after surgery, however the precise effects of these on ventilation have not been investigated. This study was designed to compare the effects of deep breathing and ambulation on pattern of breathing in patients after upper abdominal surgery. A similar increase was found in minute ventilation, however the pattern of breathing seen during each treatment was very different. During the deep breathing exercises patients had large, significant increases in tidal volume (mean change 488.5ml), while respiratory rate decreased non-significantly. By comparison, ambulation caused small and non-significant increases in both tidal volume (163.4ml) and respiratory rate. It appears that if one of the aims of ambulation is to increase tidal volume, patients may need to be encouraged to augment their tidal volumes.

100 long-term implantable left ventricular assist devices: the Columbia Presbyterian interim experience

BACKGROUND

The use of left ventricular assist devices (LVADs) as bridge to transplantation is now accepted as a standard of care for a subset of end-stage heart failure patients. Our interim experience with both pneumatically and electrically powered ThermoCardiosystems LVADs is presented to outline the benefits and limitations of device support as well as discuss its potential role as bridge to recovery and as destination therapy.

METHODS AND RESULTS

Detailed records were kept prospectively for all patients undergoing LVAD insertion. One hundred LVADs were inserted over 7 years into 95 patients, with an overall survival rate of 75% and a transplantation rate of 70%. Four patients underwent device explant for recovered myocardial function. Three patients received LVADs as destination therapy in the ongoing REMATCH (Randomized Evaluation of Mechanical Assist Treatment for Congestive Heart failure) trial. Overall mean patient age was 51 years, and mean duration of support was 108 days. There were 25 device-related infections including the drive line, device pocket, and blood-contacting surfaces. Cerebral vascular accidents and other embolic events occurred in 7 patients with six deaths. There were four device malfunctions and nine graft-related hemorrhages, resulting in six reoperations and three deaths.

CONCLUSIONS

The use of long-term implantable LVADs will likely not be limited to bridge to transplantation. The REMATCH trial has commenced to study the role LVADs may have as an alternative to medical management. Furthermore, as the issues of myocardial recovery are examined, the "bridge to recovery" may be an important additional role for these assist devices.

Bridge experience with long-term implantable left ventricular assist devices. Are they an alternative to transplantation?

BACKGROUND

If long-term use of left ventricular assist devices (LVADs) as bridges to transplantation is successful, the issue of permanent device implantation in lieu of transplantation could be addressed through the creation of appropriately designed trials. Our medium-term experience with both pneumatically and electrically powered ThermoCardiosystems LVADs is presented to outline the benefits and limitations of device support in lieu of transplantation.

METHODS AND RESULTS

Detailed records were kept prospectively for all patients undergoing LVAD insertion. Fifty-eight LVADs were inserted over 5 years, with a survival rate of 74%. Mean patient age was 50 years, and duration of support averaged 98 days. Although common, both preexisting infection and infection during LVAD support were not associated with increased mortality or decreased rate of successful transplantation. Thromboembolic complications were rare, occurring in only three patients (5%) despite the absence of anticoagulation. Ventricular arrhythmias were well tolerated in all patients except in cases of early perioperative right ventricular failure, with no deaths. Right ventricular failure occurred in one third of patients and was managed in a small percentage by right ventricular assist device (RVAD) support and/or inhaled nitric oxide therapy. There were no serious device malfunctions, but five graft-related hemorrhages resulted in two deaths. Finally, a variety of noncardiac surgical procedures were performed in LVAD recipients, with no major morbidity and mortality.

CONCLUSIONS

Over all, our medium-term experience with implantable LVAD support is encouraging. Although additional areas of investigation exist, improvements in patients selection and management together with device alterations that have reduced the thromboembolic incidence and facilitated patient rehabilitation lead us to believe that a prospective, randomized trial is indicated to study the role that LVADs may have as an alternative to medical management.