Biomedical subjects

E A Rose

Publications and source records attributed to E A Rose.

At least 73 records · Page 4Linked to original sources

PubMed1997

Improved results for postcardiotomy cardiogenic shock with the use of implantable left ventricular assist devices.

BACKGROUND: Over the past decade, the use of mechanical circulatory support in patients with postcardiotomy cardiogenic shock has resulted in hospital discharge rates of 25% to 40%. In an attempt to improve patient survival, we initiated a program of early insertion of an implantable Thermocardiosystems Incorporated Heartmate left ventricular assist device in patients who have circulatory failure after having undergone high-risk cardiac operations. METHODS: Between April 1993 and February 1997, 12 patients underwent insertion of an implantable left ventricular assist device for postcardiotomy cardiogenic shock after coronary artery bypass grafting. Indications for insertion included postoperative cardiogenic shock (7 patients), postoperative cardiac arrest (3 patients), and failure to wean from cardiopulmonary bypass (2 patients). RESULTS: The median time to device insertion was 3.5 days. The mean duration of left ventricular assist device support was 103 +/- 19 days (range, 2 to 225 days). Nine of 11 patients (82%) survived to undergo either transplantation (8 patients) or explantation (1 patient), with successful hospital discharge of all 9 patients. The major complication was device-related infection (42%). A single thromboembolism occurred in a patient with an infection. CONCLUSIONS: Long-term outcome after postcardiotomy cardiogenic shock is improved substantially with the use of an implantable left ventricular assist device early in the postoperative course. Access to such a device is an important consideration before undertaking a high-risk cardiac operation, and early implantation of the device is a critical factor in ensuring long-term survival.

Algorithms↗

PubMed1997

The continuing evolution of mechanical ventricular assistance.

A great number of patients suffer and die of the sequelae of acute and chronic heart failure each year. Although advances in medical and surgical therapy have benefited many of these patients, most have disease that is refractory to any definitive therapy. For these patients cardiac transplantation is the only remaining hope. Unfortunately, because of the increasing demand for donor organs in the face of a fixed and limited supply, this option is available to only a small percentage of these patients. Even in patients accepted for transplantation, a significant waiting list mortality has been observed. A variety of VADs have been developed since the first successful case of mechanical cardiac assistance more than 30 years ago. These devices differ in basic mechanical function, method of insertion, and degree of implantability and thus have different indications and potential applications. Whereas the intraaortic balloon pump and centrifugal pumps are effective short-term support modalities, extracorporeal and implantable pulsatile devices have been used successfully for long-term support of patients with reversible and nonreversible cardiac failure. Although these pumps have most commonly been used as bridges to transplantation, increasing clinical experience has supported the notion of long-term mechanical assistance as a definitive therapy for patients with end-stage heart disease. Although complications, particularly infection and thromboembolism, pose significant challenges and long-term device reliability remains to be fully determined, available implantable devices appear to be capable of providing effective long-term support. As data are obtained from currently ongoing trials comparing VAD support with medical therapy for end-stage heart failure, ethical and economic issues will assume increasing importance.

Cardiac Output, Low↗

PubMed1997

Long-term survivors of pediatric heart transplantation: a multicenter report of sixty-eight children who have survived longer than five years.

OBJECTIVE: Short-term survival after pediatric heart transplantation is now excellent, but ultimately the efficacy of this procedure will depend on duration and quality of survival. We sought to evaluate the clinical course of long-term survivors of heart transplantation in childhood. METHODS: Patients who had undergone heart transplantation at the university hospitals of Stanford, Columbia, and Pittsburgh between 1975 and 1989 and survived longer than 5 years from transplantation were identified and their clinical courses retrospectively reviewed. RESULTS: Sixty eight children have survived more than 5 years from transplantation, and 60 (88%) are currently alive with a median follow-up of 6.8 years (5 to 17.9 years). Thirteen have survived more than 10 years from transplantation. Renal dysfunction caused by immunosuppressive agents was common, and two patients required late renal transplantation. Lymphoproliferative disease or other neoplasm occurred in 12 patients, but none resulted in death. Coronary artery disease was diagnosed in 13 patients (19%), leading to retransplantation in eight. Death after 5 years was related to acute or chronic rejection in 5 of 8 cases. Two of the deaths were directly related to noncompliance with immunosuppressive medication. All survivors are in New York Heart Association class 1. CONCLUSIONS: Long-term survival with good quality of life can be achieved after heart transplantation in childhood, though complications of immunosuppression remain common. Posttransplantation coronary artery disease is emerging as the main factor limiting long term graft and patient survival.

Adolescent↗

PubMed1997

Reevaluating the significance of pulmonary hypertension before cardiac transplantation: determination of optimal thresholds and quantification of the effect of reversibility on perioperative mortality.

OBJECTIVES: Right-sided circulatory failure resulting from severe preoperative pulmonary hypertension is a source of mortality early after cardiac transplantation. We undertook the present study (1) to analyze the association of elevated pulmonary hemodynamic indices with 30-day mortality, (2) to define threshold ranges associated with an increase in 30-day mortality, and (3) to evaluate the effect of vasodilator reversibility on 30-day mortality. METHODS: Preoperative hemodynamic profiles were evaluated in 476 patients who ultimately underwent cardiac transplantation. From these data, receiver-operating characteristic curves and stratum-specific likelihood ratios were generated to compare the efficacy of each hemodynamic index. A subset of patients with elevated hemodynamic profiles at baseline additionally underwent graded sodium nitroprusside infusion. RESULTS: Analysis of receiver-operating characteristic curves demonstrated no statistically significant difference among the indices in their ability to predict 30-day mortality. Analysis of stratum-specific likelihood ratios demonstrated three risk strata that correlated with significant differences in 30-day mortality, with patients in the high-risk stratum having a 3.2 to 4.4 increase in odds of 30-day mortality when compared with patients in the low-risk stratum. Nitroprusside data demonstrated that although 30-day mortality was better in patients with reversible pulmonary hypertension than in those with fixed pulmonary hypertension, it was not comparable with that of patients without pulmonary hypertension at baseline. CONCLUSIONS: Candidates for cardiac transplantation may be categorized into three risk strata on the basis of their preoperative pulmonary hemodynamic profile; the association of this profile with 30-day mortality is not linear. Reversibility with nitroprusside appears to confer some improvement in the risk of 30-day mortality, but it may not eliminate the risk entirely.

Cardiac Catheterization↗

PubMed1997

Cerebral dysfunction after coronary artery bypass grafting done with mild or moderate hypothermia.

OBJECTIVE: Ninety-nine patients undergoing elective coronary artery bypass grafting were enrolled in a prospective, randomized study to evaluate the incidence of cerebral dysfunction after "mild" or "moderate" hypothermia during cardiopulmonary bypass. METHODS: Patients were evaluated before and after operation before hospital discharge and in some cases at follow-up at least 6 weeks later with a complete neurologic examination (85 patients) and a battery of standard neuropsychometric tests (86 patients). RESULTS: Postoperative changes detected by neurologic examination consisted of the appearance of new primitive reflexes in both groups. No statistically significant differences in incidence were found. The neuropsychometric performances of the two groups were statistically similar by either event-rate or group-rate analysis. CONCLUSIONS: There is no detectable difference in postoperative cerebral dysfunction in patients undergoing coronary artery bypass grafting who are supported by cardiopulmonary bypass with either mild or moderate hypothermia.

Aged↗

PubMed1997

Retrograde cardioplegia preserves myocardial function after induced coronary air embolism.

Coronary air embolism is a potential complication of cardiopulmonary bypass. We compared left ventricular function before and after the administration of antegrade or retrograde cardioplegic solution in a porcine model of coronary air embolism. Nineteen pigs were placed on cardiopulmonary bypass support and cooled to 32 degrees C. The heart was initially arrested with antegrade cold blood cardioplegic solution. The aortic crossclamp was released at 30 minutes and 0.02 cc/kg body weight of air was injected into the left anterior descending artery distal to the first diagonal branch. After 5 minutes the aorta was reclamped and the animals treated with 15 ml/kg body weight of 1:4 blood cardioplegic solution delivered by the antegrade (n = 6) or retrograde (n = 7) method. Control animals (n = 6) were not treated. Changes in regional preload recruitable stroke work were used to assess left ventricular performance before and after cardiopulmonary bypass. Two control animals could not be weaned from cardiopulmonary bypass. Left ventricular function was best preserved after treatment of induced coronary air embolism with retrograde cardioplegia (90% of baseline). Coronary air embolism treatment with antegrade cardioplegia resulted in diminished left ventricular performance (68% of baseline). In control animals left ventricular contractility was significantly impaired (39% of baseline). We conclude that administration of retrograde cardioplegic solution may be an effective method of treating coronary air embolism. The favorable outcome seen with cardioplegia may be in part because of its ability to protect the ischemic myocardium while the solution mechanically dislodges air from the vascular bed.

Animals↗

PubMed1997

Heart reduction surgery: an analysis of the impact on cardiac function.

OBJECTIVES: Reports of improved ejection fraction, coupled with decreased filling pressures, have prompted a number of centers to begin evaluating the efficacy of heart reduction surgery to ameliorate symptoms of heart failure. However, the impact of this operation on cardiac mechanics is unknown. We applied a multiple compartment elastance model to simulate the effects of excising cardiac mass on heart function. METHODS: The left ventricle was divided into two functional compartments to simulate excision of part of the wall. At multiple increments of mass reduction, the resulting end-systolic elastance, ejection fraction, stroke volume, end-diastolic pressure and volume, and diastolic stiffness were determined. RESULTS: Changes in systolic function were accompanied by offsetting changes in diastolic function; consequently, overall pump function (the Frank-Starling Relationship) was found to be depressed. The geometric rearrangement associated with this operation leads to a reduction in wall stress for a given level of pressure generation, thus implying an increase in the efficiency with which wall stress is transduced into intraventricular pressure. CONCLUSIONS: Overall pump function is depressed in the short run after heart reduction surgery. However, on the basis of theoretic arguments, heart reduction surgery may have long-term beneficial implications. Importantly, this analysis revealed that changes in parameters of ventricular function have different implications during heart reduction surgery than when such changes are observed with inotropism caused by acute pharmacologic therapy.

Heart↗

PubMed1997

Implantable left ventricular assist devices provide an excellent outpatient bridge to transplantation and recovery.

OBJECTIVES: Our recent experience with outpatient left ventricular assist device (LVAD) support is presented to demonstrate the possibilities and limitations of long-term outpatient mechanical circulatory assistance. BACKGROUND: The experience with inpatient LVAD support as a bridge to transplantation has proved the efficacy of such therapy in improving circulatory hemodynamic status, restoring normal end-organ function and facilitating patient rehabilitation. With miniaturization of the power supplies and controllers, such mechanical circulatory support can now be accomplished in an outpatient setting. METHODS: Between March 1993 and February 1997, 32 patients (26 male, 6 female, mean [+/-SEM] age 49 +/- 15 years) underwent implantation of the ThermoCardiosystems (TCI) Heartmate vented electric (VE) LVAD. The VE LVAD is powered by batteries worn on shoulder holsters and is operated by a belt-mounted system controller, allowing unrestricted patient ambulation and hospital discharge. RESULTS: Mean duration of support was 122 +/- 26 days (range 3 to 605), with a survival rate to transplantation or explantation of 78%. Nineteen patients were discharged from the hospital on mean postoperative day 41 +/- 4 (range 17 to 68), for an outpatient support time of 108 +/- 30 days (range 2 to 466). Four patients underwent early transplantation and could not participate in the discharge program, and three patients currently await discharge. The complication rate was not statistically different from that encountered in our previous 52 patients with a pneumatic LVAD. CONCLUSIONS: Outpatient LVAD support is safe and provides improved quality of life for patients awaiting transplantation. Wearable and totally implantable LVADs should be studied as permanent treatment options for patients who are not candidates for heart transplantation.

Ambulatory Care↗

PubMed1997

Implantable left ventricular assist devices: an evolving long-term cardiac replacement therapy.

OBJECTIVE: The authors' 8-year experience with both inpatient and outpatient left ventricular assist device (LVAD) support is presented to show the possibilities and limitations of long-term outpatient mechanical circulatory assistance. SUMMARY BACKGROUND DATA: The limitation of suitable cardiac donors has led to the use of LVADs as a temporizing measure for patients awaiting cardiac transplantation. The success of such devices in the short and medium term as a bridge to transplantation has led to their evaluation as a long-term destination therapy for end-stage heart disease. METHODS: Between August 1990 and February 1997, 85 patients with end-stage heart disease underwent insertion of implantable LVADs. Fifty-two patients underwent pneumatic device insertion and 32 patients received a vented electric device. RESULTS: Patients were supported for a mean of 109+/-13 days for an overall survival to transplant (54) or explant (3) of 73%. Nineteen patients were discharged from the hospital on a mean of postoperative day 41+/-4 (range, 17-68) for an outpatient support time of 108+/-30 days (range, 2-466). Of 12 patients supported after postcardiotomy cardiogenic shock, 10 (82%) survived to hospital discharge. Perioperative right ventricular failure was treated in most patients with inotropic agents and inhaled nitric oxide with only six patients requiring right ventricular assist device support. Thromboembolic rate was low (0.016 events/patient-month) despite minimal or no anticoagulation in all cases. CONCLUSIONS: Left ventricular assist device support has evolved to become an outpatient therapy with excellent survival rates and an acceptable morbidity. Accordingly, wearable LVADs should be studied as permanent treatment options for patients who are not transplant candidates.

Ambulatory Care↗

PubMed1997

Sympathetic response during cardiopulmonary bypass: mild versus moderate hypothermia.

OBJECTIVE: To determine the sympathetic response during cardiopulmonary bypass at mild (34 degrees C) and moderate (28 degrees C) hypothermia. DESIGN: A randomized study. SETTING: Tertiary university hospital. PATIENTS: Adults undergoing elective coronary artery bypass graft surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Plasma norepinephrine, epinephrine, and neuropeptide Y concentrations were measured. Moderate, but not mild, hypothermic cardiopulmonary bypass evoked a significant sympathetic response with increases in plasma norepinephrine and neuropeptide Y concentrations. A significantly higher incidence of postoperative atrial fibrillation was also observed in the moderate hypothermic compared with the mild hypothermic group. CONCLUSIONS: Our results indicate that the degree of hypothermia significantly influences the sympathetic response during cardiopulmonary bypass. The higher incidence of postoperative atrial fibrillation in the moderate hypothermic group suggests that the enhanced sympathetic response might be one contributing factor in the development of atrial fibrillation.

Aged↗

PubMed1997

Treatment of endstage heart disease with mechanical circulatory assistance.

A great number of patients suffer and die from the sequelae of acute and chronic heart failure each year. Although advances in medical and surgical therapy have benefited many of these patients, the majority suffer from disease refractory to any definitive therapy. For these patients, cardiac transplantation is the only remaining hope. Unfortunately, because of the increasing demand for donor organs in the face of a fixed and limited supply, this option is only available to a small percentage of these patients. Even in patients accepted for transplantation, a significant waiting list mortality has been observed. A variety of ventricular assist devices (VAD) have been developed since the first successful case of mechanical cardiac assistance over 30 years ago. These devices differ in basic mechanical function, method of insertion, and degree of implantability, and thus have different indications and potential applications. While the intra-aortic balloon pump and centrifugal pumps are effective short-term support modalities, extracorporeal and implantable pulsatile devices have been used successfully for long-term support of patients with reversible and non-reversible cardiac failure. These pumps have most commonly been utilized as bridges to transplantation, but increasing clinical experience has supported the notion of long-term mechanical assistance as a definitive therapy for endstage heart disease. While complications, particularly infection and thromboembolism, pose significant challenges and long-term device reliability remains to be fully determined, available implantable devices seem capable of providing effective long-term support. As data is obtained from currently ongoing trials comparing VAD support to medical therapy for endstage heart failure, ethical and economic issues will assume increasing importance.

Assisted Circulation↗

PubMed1997

Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial.

OBJECTIVE: The role of complementary medicine techniques has generated increasing interest in today's society. The purpose of our study was to evaluate the effects of one technique, self-hypnosis, and its role in coronary artery bypass surgery. We hypotesize that self-hypnosis relaxation techniques will have a positive effect on the patient's mental and physical condition following coronary artery bypass surgery. EXPERIMENTAL DESIGN: A prospective, randomized trial was conducted. Patients were followed beginning one day prior to surgery until the time of discharge from the hospital. SETTING: The study was conducted at Columbia Presbyterian Medical Center, a large tertiary care teaching institution. PATIENTS: All patients undergoing first-time elective coronary artery bypass surgery were eligible. A total of 32 patients were randomized into two groups. INTERVENTIONS: The study group was taught self-hypnosis relaxation techniques preoperatively, with no therapy in the control group. MEASURES: Outcome variables studied included anesthetic requirements, operative parameters, postoperative pain medication requirements, quality of life, hospital stay, major morbidity and mortality. RESULTS: Patients who were taught self-hypnosis relaxation techniques were significantly more relaxed postoperatively compared to the control group (p=0.032). Pain medication requirements were also significantly less in patients practising the self-hypnosis relaxation techniques that those who were noncompliant (p=0.046). No differences were noted in intraoperative parameters, morbidity or mortality. CONCLUSION: This study demonstrates the beneficial effects self-hypnosis relaxation techniques on patients undergoing coronary artery bypass surgery. It also provides a framework to study complementary techniques and the limitations encountered.

Aged↗

PubMed1997

The influence of infection on survival and successful transplantation in patients with left ventricular assist devices.

BACKGROUND: Mechanical cardiac assistance has recently emerged as a tenable option in the treatment of end-stage heart failure. In spite of recent technical improvements that have reduced the incidence of life-threatening complications, the reported frequency of infections in these patients has remained high. METHODS: Over a 5-year period, 60 patients underwent insertion of a left ventricular assist device (LVAD) at our institution. Detailed medical records were kept prospectively for all patients, and a variety of endpoints were analyzed, including the incidence, nature, and sequelae of infections before and after LVAD implantation and after transplantation. RESULTS: Twenty-nine of 60 patients (48%) undergoing LVAD insertion subsequently had development of infections. The most frequent sites of infection were blood, LVAD drivelines, and central venous catheters, representing 61% of all infections. At the time of LVAD implantation, 13 of 60 patients (22%) had culture-proven infections. In spite of an increased incidence of subsequent infection (77% vs 40%), there were no differences in rates of mortality (31% vs 26%), LVAD endocarditis, (23% vs 11%) and eventual transplantation (62% vs 57%) between these patients and those without periimplantation infections. Although the overall mortality rate was not influenced by infections during LVAD support (28% vs 26%), the development of LVAD endocarditis was associated with a high mortality rate. Finally, although patients with infections during LVAD support had significantly longer median support times than those who remained infection free (101 vs 49 days, respectively), there was no difference in the rate of successful transplantation (59% vs 58%) or in the rate of infection after transplantation (35% vs 28%). CONCLUSIONS: Infections are common in patients undergoing LVAD support, but they do not adversely affect survival, the rate of successful transplantation, or the incidence of posttransplantation infection. Periimplantation infections may increase the risk of subsequent infections, but they also do not influence survival or transplantability. Patients with development of LVAD endocarditis are at increased risk for morbidity and death and require early and aggressive therapy, potentially including device explantation.

Adolescent↗

PubMed1997

Cardiac transplantation for endstage heart disease.

Orthotopic heart transplantation (OHT), first accomplished in 1967, is currently performed in over 2000 patients per year at hundreds of centers worldwide. Selection criteria include end-stage heart failure with a limited life expectancy, intractable angina due to inoperable coronary artery disease, malignant ventricular arrhythmias refractory to maximal therapy, and unresectable cardiac tumors. While early immunosuppression was based on azathioprine and steroids, the current success of OHT is based on the addition of cyclosporine A (CyA) to this regimen. At Columbia-Presbyterian Medical Center, steroids and azathioprine are given perioperatively, and cyclosporine (OKT3 in patients with renal dysfunction) begun postoperatively. Survival rates at our institution parallel those reported by other centers, with 1- and 5-year actuarial survival of 85% and 70%, respectively. The most frequent causes of early mortality are allograft rejection and infection, while graft coronary artery disease (CAD) is responsible for most deaths occurring after the first post-transplant year. Regular endomyocardial biopsy is used to monitor for rejection, which occurs in 55% of patients within the first year. Mild or asymptomatic rejection is managed with oral steroids, followed by intravenous steroids and/or OKT3 or anti-thymocyte globulin (ATG) in refractory cases. Graft CAD occurs in 45% of patients surviving 3 years, and may require retransplantation. Heart transplantation is a proven, effective form of cardiac replacement. The recent trend of increasingly critically ill transplant candidates, however, has driven the costs of OHT to unprecedented levels. This issue, as well as the continuing organ short-age and current developments in mechanical cardiac assistance and xenotransplantation will undoubtedly assure a continually evolving role for cardiac transplantation in the treatment of endstage heart disease.

Costs and Cost Analysis↗

PubMed1996

Indirect recognition of donor HLA-DR peptides in organ allograft rejection.

To determine whether indirect allorecognition is involved in heart allograft rejection T cells obtained from peripheral blood and graft biopsy tissues were expanded in the presence of IL-2 and tested in limiting dilution analysis (LDA) for reactivity to synthetic peptides corresponding to the hypervariable regions of the mismatched HLA-DR antigen(s) of the donor. Serial studies of 32 patients showed that T cell reactivity to donor allopeptides was strongly associated with episodes of acute rejection. The frequency of allopeptide reactive T cells was 10-50-fold higher in the graft than in the periphery indicating that T cells activated via the indirect allorecognition pathway participate actively in acute allograft rejection. In recipients carrying a graft differing by two HLA-DR alleles the response appeared to target only one of the mismatched antigens of the donor. Indirect allorecognition was restricted by a single HLA-DR antigen of the host and directed against one immunodominant peptide of donor HLA-DR protein. However, intermolecular spreading was demonstrated in patients with multiple rejection episodes by showing that they develop allopeptide reactivity against the second HLA-DR antigen. These data imply that early treatment to suppress T cell responses through the indirect pathway of allorecognition, such as tolerance induction to the dominant donor determinant, may be required to prevent amplification and perpetuation of the rejection process.

Cells, Cultured↗

PubMed1996

Immunologic monitoring in lung allograft recipients.

To identify patients with increased risk of chronic lung allograft rejection, we assessed the utility of an in vitro biopsy-derived lymphocyte growth assay and serum anti-HLA antibody screening as a complement to currently available methods of monitoring lung allograft recipients. Lymphocyte growth assay was performed on bronchoscopic fragments of tissue cultured in medium with rIL-2. Seventy-nine biopsies from 31 lung transplant recipients were tested by lymphocyte growth assay, and results were correlated with histopathology findings. Positive lymphocyte growth was found in 12/26 (46%) episodes of acute rejection, 5/44 biopsies without rejection (11%), and 0/9 episodes of bronchitis. Positive lymphocyte growth was seen in 7/16 (44%) grade A1 rejections and in 5/10 (50%) grade A2 rejections, as opposed to only 5/44 (11%) grade A0 (no rejection) biopsies (P < 0.01 for both A1 and A2 with respect to A0). Actuarial probability of remaining free from obliterative bronchiolitis (OB)* tended to be higher in patients who did not exhibit lymphocyte growth in biopsies. Sequential samples of sera obtained at the time of the biopsy were screened for lymphocytotoxic anti-HLA antibodies. Twenty-two of 44 recipients (50%) developed anti-HLA antibodies during the first postoperative year, exhibiting greater than 10% reactivity to an HLA reference panel of lymphocytes in four or more consecutive serum samples. Actuarial survival of lung allograft recipients with anti-HLA antibodies (n = 22) was lower than in those without anti-HLA antibodies (n = 22; P = 0.03). Of the 22 antibody producers, 7/12 died as a consequence of OB. Of the 22 non-antibody-producers, 1/2 deaths occurred as a consequence of OB. Anti-HLA antibodies were present in 9/11 instances of OB (82% sensitivity) and in 13/33 patients without OB (61% specificity; P = 0.03). These data indicate that lung transplant recipients with positive lymphocyte growth and anti-HLA antibodies are at an increased risk of chronic allograft rejection.

Antibodies↗

PubMed1996

Wearable long-term mechanical support for patients with end-stage heart disease: a tenable goal.

Increasing in frequency, and claiming more than 250,000 lives per year, heart failure represents a major public health problem. In spite of newer medical therapies, a significant proportion of patients progress to irreversible end-stage heart disease, for which cardiac transplantation remains the only long term hope. The inability to meet the demand for donor organs has led to the development of left ventricular assist devices as a temporizing measure while awaiting a transplantation. The "bridging to transplantation" experience has firmly established the efficacy of these devices as short-term and medium-term mechanical assistance and has provided valuable lessons applicable to long-term support. Mechanical cardiac assistance technology has dramatically improved and can provide reliable univentricular support with minimal thromboembolic and infectious complications. Although major obstacles remain, the potential benefits are great enough and the morbidity and mortality of end-stage heart disease high enough to warrant the evaluation of wearable left ventricular assist devices for long-term mechanical assistance.

Cardiac Output, Low↗

PubMed1996

Experience with right ventricular assist devices for perioperative right-sided circulatory failure.

BACKGROUND: Right-sided circulatory failure remains a significant source of morbidity and mortality for both cardiac transplant and left ventricular assist device recipients. METHODS: We reviewed our experience with 11 patients who required a right ventricular assist device (RVAD) after either orthotopic heart transplantation or left ventricular assist device implantation. Variables analyzed included total time of RVAD support, hemodynamic and hematologic parameters, and parameters of end-organ perfusion. These were assessed at five time points: (1) at least 2 weeks before RVAD implantation, (2) intraoperatively just before RVAD insertion, (3) while on RVAD support, and, for those who survived, (4) just before RVAD explantation, and (5) off RVAD support. Survival was assessed as the ability to be weaned successfully from RVAD support. Urine output and serum transaminase levels were recorded throughout the period of RVAD support. RESULTS: Five patients received an ABIOMED 5000 BVS RVAD, and 6 received a Bio-Medicus centrifugal pump. Nine patients in the study underwent orthotopic heart transplantation and had development of right-sided circulatory failure from 0 to 96 hours after donor organ insertion, and 2 patients underwent left ventricular assist device implantation 12 to 48 hours before RVAD support. The mean time of RVAD support for survivors was 133.6 +/- 33.6 hours (range, 107 to 190 hours). Six patients were successfully separated from RVAD support, and 5 patients died while on RVAD support. Causes of death included sepsis (2), biventricular failure (2), and coagulopathy (1). Continuous arteriovenous hemodialysis was employed in 3 of 6 survivors and 1 of 5 nonsurvivors. CONCLUSIONS: Right ventricular assist devices work most effectively if implanted early enough to avoid significant, potentially irreversible end-organ injury. We liberally employ continuous arteriovenous hemodialysis, minimize the use of heparin immediately postoperatively, keep patients sedated, and continue RVAD support until the patient displays signs of hemodynamic and end-organ recovery as heralded by (1) a decrease in central venous pressure and, more importantly, a decrease in pulmonary artery diastolic pressure, (2) an increase in urine output, and (3) a decrease in serum transaminase levels.

Adolescent↗