Intermediate- and long-term mechanical circulatory support
- Emma Jane Birks, MD, PhD, FRCP
Emma Jane Birks, MD, PhD, FRCP
- Professor of Medicine
- University of Louisville
- Division of Cardiovascular Medicine
- Director of Advanced Heart Failure, Transplant and Mechanical Support
- Jewish Hospital & St. Mary's HealthCare
- Section Editors
- Donna Mancini, MD
Donna Mancini, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Icahn School of Medicine at Mount Sinai
- Sharon A Hunt, MD
Sharon A Hunt, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Heart Transplantation
- Professor of Medicine
- Stanford University School of Medicine
Medical therapy (including angiotensin converting enzyme inhibitors, beta blockers, and aldosterone antagonists), cardiac resynchronization therapy, and implantable cardioverter-defibrillators have improved the survival of many with heart failure with reduced ejection fraction (HFrEF), but there remains a large group of patients who have advanced heart failure with poor prognosis despite optimal medical therapy. Unfortunately, the numbers of useable donor hearts available to perform heart transplantation for these patients has not increased in the US and has actually decreased in Europe over recent years and the supply is and will remain inadequate for the population who could benefit from heart transplantation. (See "Overview of the therapy of heart failure with reduced ejection fraction".)
Mechanical support of the circulation with left ventricular assist devices (LVADs) is a rapidly evolving field. LVADs are efficient devices that assist and support the circulation and they are being inserted into an increasing number of patients with advanced HFrEF. Mechanical circulatory support with a ventricular assist device (VAD) is a life-saving therapy for patients with decompensating advanced heart failure who fail to improve or stabilize with optimal medical therapy.
This topic will discuss intermediate- and long-term VAD therapy. Short-term mechanical support and practical management of long-term mechanical circulatory support are discussed separately. (See "Short-term mechanical circulatory assist devices" and "Practical management of long-term mechanical circulatory support devices".)
CATEGORIES OF USE
A VAD can be used as a bridge to cardiac transplantation (to sustain life until a donor heart becomes available), as a bridge to decision (regarding transplant eligibility), as destination (or permanent) therapy, or as a bridge to recovery of heart function. Most patients receiving mechanical cardiac support for these indications receive a left ventricular assist device (LVAD) with less than 15 percent receiving biventricular support in the form of biventricular device (BiVAD; left plus right ventricular support) or total artificial heart (TAH) .
Bridge to transplantation — Intermediate- or long-term left ventricular assist devices (LVADs) can be used as bridges to transplantation (BTT) in patients with advanced heart failure with deteriorating clinical status who are or may be candidates for heart transplantation but are too unstable to wait any longer without circulatory support. LVADs are inserted into patients who have worsening New York Heart Association (NYHA) Class IIIb or IV heart failure (table 1) often despite inotropic plus intraaortic balloon pump support. Such patients often also have end organ dysfunction or other potentially reversible medical conditions that may be temporary contraindications to cardiac transplantation (for which LVAD use may be considered a “bridge to candidacy” or “bridge to decision”) . Not only are LVADs life-saving in these deteriorating patients who might otherwise die before a donor heart becomes available, but they can also improve secondary organ function prior to transplantation, reduce pulmonary hypertension, and enable improvement in nutritional status, all of which are associated with improved post-transplant survival.
- Cleveland JC Jr, Naftel DC, Reece TB, et al. Survival after biventricular assist device implantation: an analysis of the Interagency Registry for Mechanically Assisted Circulatory Support database. J Heart Lung Transplant 2011; 30:862.
- McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
- Aurora P, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report--2010. J Heart Lung Transplant 2010; 29:1129.
- Lietz K, Miller LW. Improved survival of patients with end-stage heart failure listed for heart transplantation: analysis of organ procurement and transplantation network/U.S. United Network of Organ Sharing data, 1990 to 2005. J Am Coll Cardiol 2007; 50:1282.
- Kirklin JK, Naftel DC, Pagani FD, et al. Sixth INTERMACS annual report: a 10,000-patient database. J Heart Lung Transplant 2014; 33:555.
- Kirklin JK, Naftel DC, Pagani FD, et al. Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transplant 2015; 34:1495.
- Birks EJ, Tansley PD, Hardy J, et al. Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med 2006; 355:1873.
- Birks EJ, George RS, Hedger M, et al. Reversal of severe heart failure with a continuous-flow left ventricular assist device and pharmacological therapy: a prospective study. Circulation 2011; 123:381.
- Wong K, Boheler KR, Bishop J, et al. Clenbuterol induces cardiac hypertrophy with normal functional, morphological and molecular features. Cardiovasc Res 1998; 37:115.
- Haj-Yahia S, Birks EJ, Rogers P, et al. Midterm experience with the Jarvik 2000 axial flow left ventricular assist device. J Thorac Cardiovasc Surg 2007; 134:199.
- Mehra M, Naka Y, Uriel N, et al. A fully magnetically levitated circulatory pump for advanced heart failure. N Engl J Med 2016.
- Krabatsch T, Potapov E, Stepanenko A, et al. Biventricular circulatory support with two miniaturized implantable assist devices. Circulation 2011; 124:S179.
- Meyer A, Slaughter M. The total artificial heart. Panminerva Med 2011; 53:141.
- Mehra MR, Canter CE, Hannan MM, et al. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. J Heart Lung Transplant 2016; 35:1.
- Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
- Drakos SG, Janicki L, Horne BD, et al. Risk factors predictive of right ventricular failure after left ventricular assist device implantation. Am J Cardiol 2010; 105:1030.
- Matthews JC, Koelling TM, Pagani FD, Aaronson KD. The right ventricular failure risk score a pre-operative tool for assessing the risk of right ventricular failure in left ventricular assist device candidates. J Am Coll Cardiol 2008; 51:2163.
- Fitzpatrick JR 3rd, Frederick JR, Hsu VM, et al. Risk score derived from pre-operative data analysis predicts the need for biventricular mechanical circulatory support. J Heart Lung Transplant 2008; 27:1286.
- Drakos SG, Wever-Pinzon O, Selzman CH, et al. Magnitude and time course of changes induced by continuous-flow left ventricular assist device unloading in chronic heart failure: insights into cardiac recovery. J Am Coll Cardiol 2013; 61:1985.
- Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001; 345:1435.
- Long JW, Kfoury AG, Slaughter MS, et al. Long-term destination therapy with the HeartMate XVE left ventricular assist device: improved outcomes since the REMATCH study. Congest Heart Fail 2005; 11:133.
- Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009; 361:2241.
- Park SJ, Milano CA, Tatooles AJ, et al. Outcomes in advanced heart failure patients with left ventricular assist devices for destination therapy. Circ Heart Fail 2012; 5:241.
- Navia JL, McCarthy PM, Hoercher KJ, et al. Do left ventricular assist device (LVAD) bridge-to-transplantation outcomes predict the results of permanent LVAD implantation? Ann Thorac Surg 2002; 74:2051.
- Frazier OH, Rose EA, Oz MC, et al. Multicenter clinical evaluation of the HeartMate vented electric left ventricular assist system in patients awaiting heart transplantation. J Thorac Cardiovasc Surg 2001; 122:1186.
- Sun BC, Catanese KA, Spanier TB, et al. 100 long-term implantable left ventricular assist devices: the Columbia Presbyterian interim experience. Ann Thorac Surg 1999; 68:688.
- Miller LW, Pagani FD, Russell SD, et al. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 2007; 357:885.
- Aaronson KD, Slaughter MS, Miller LW, et al. Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation 2012; 125:3191.
- Pagani FD, Miller LW, Russell SD, et al. Extended mechanical circulatory support with a continuous-flow rotary left ventricular assist device. J Am Coll Cardiol 2009; 54:312.
- Starling RC, Naka Y, Boyle AJ, et al. Results of the post-U.S. Food and Drug Administration-approval study with a continuous flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol 2011; 57:1890.
- Strueber M, O'Driscoll G, Jansz P, et al. Multicenter evaluation of an intrapericardial left ventricular assist system. J Am Coll Cardiol 2011; 57:1375.
- Simon MA, Kormos RL, Murali S, et al. Myocardial recovery using ventricular assist devices: prevalence, clinical characteristics, and outcomes. Circulation 2005; 112:I32.
- Mancini DM, Beniaminovitz A, Levin H, et al. Low incidence of myocardial recovery after left ventricular assist device implantation in patients with chronic heart failure. Circulation 1998; 98:2383.
- Dandel M, Weng Y, Siniawski H, et al. Prediction of cardiac stability after weaning from left ventricular assist devices in patients with idiopathic dilated cardiomyopathy. Circulation 2008; 118:S94.
- Farrar DJ, Holman WR, McBride LR, et al. Long-term follow-up of Thoratec ventricular assist device bridge-to-recovery patients successfully removed from support after recovery of ventricular function. J Heart Lung Transplant 2002; 21:516.
- George RS, Yacoub MH, Bowles CT, et al. Quality of life after removal of left ventricular assist device for myocardial recovery. J Heart Lung Transplant 2008; 27:165.
- Birks EJ, Hall JL, Barton PJ, et al. Gene profiling changes in cytoskeletal proteins during clinical recovery after left ventricular-assist device support. Circulation 2005; 112:I57.
- Hall JL, Birks EJ, Grindle S, et al. Molecular signature of recovery following combination left ventricular assist device (LVAD) support and pharmacologic therapy. Eur Heart J 2007; 28:613.
- Latif N, Yacoub MH, George R, et al. Changes in sarcomeric and non-sarcomeric cytoskeletal proteins and focal adhesion molecules during clinical myocardial recovery after left ventricular assist device support. J Heart Lung Transplant 2007; 26:230.
- Cullen ME, Yuen AH, Felkin LE, et al. Myocardial expression of the arginine:glycine amidinotransferase gene is elevated in heart failure and normalized after recovery: potential implications for local creatine synthesis. Circulation 2006; 114:I16.
- Terracciano CM, Harding SE, Adamson D, et al. Changes in sarcolemmal Ca entry and sarcoplasmic reticulum Ca content in ventricular myocytes from patients with end-stage heart failure following myocardial recovery after combined pharmacological and ventricular assist device therapy. Eur Heart J 2003; 24:1329.
- Copeland JG, Smith RG, Arabia FA, et al. Cardiac replacement with a total artificial heart as a bridge to transplantation. N Engl J Med 2004; 351:859.
- Copeland JG, Copeland H, Gustafson M, et al. Experience with more than 100 total artificial heart implants. J Thorac Cardiovasc Surg 2012; 143:727.
- Kirsch M, Mazzucotelli JP, Roussel JC, et al. Survival after biventricular mechanical circulatory support: does the type of device matter? J Heart Lung Transplant 2012; 31:501.
- CATEGORIES OF USE
- Bridge to transplantation
- Bridge to decision
- Destination therapy
- Bridge to recovery
- DEVICE OPTIONS
- FIRST GENERATION DEVICES
- HeartMate I device
- Thoratec paracorporeal ventricular assist device (PVAD)
- SECOND GENERATION DEVICES
- HeartMate II
- Jarvik 2000
- Berlin Heart INCOR
- THIRD GENERATION PUMPS
- Heartmate 3
- BIVENTRICULAR SUPPORT
- Total artificial heart
- CLINICAL USE
- CLINICAL EVIDENCE
- As destination therapy
- As a bridge to transplantation
- As a bridge to recovery
- Biventricular support
- - Biventricular device
- - Total artificial heart
- - Comparison of type of biventricular support
- SUMMARY AND RECOMMENDATIONS