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left ventricular assist device (LVAD)

Mechanical left ventricular assist device. Indications: - NYHA class 4 heart failure a) *prior to cardiac transplantation b) recovery from cardiogenic shock c) primary therapy* d) *in connection with combination drug therapy# * case of placing LVAD in 73 yo woman with BP of 161/112 mm Hg, HR of 144/min, LVEF of 20%, moderate mitral regurgitation [15] Contraindications: - mortality very high in patients with ESRD [10] Procedure: - continuous flow device superior to pulsatile flow device [3] - intrapericardial centrifugal flow device non inferior to axial flow device [9] - centrifugal-flow device superior to an axial-flow device [11] Complications: 1) infection 2) bleeding 3) device malfunction 4) stroke 5) device thrombosis [5] - magnetically levitated centrifugal-flow HeartMate 3 significantly reduced rates of thrombotic pump malfunction [8] 6) ventricular thrombus 7) acquired von-Willebrand's disease (vWD) [4] * 52% 1 year survival vs 25% with medical management # combination drug therapy 1) start lisinopril, losartan, spironolactone, carvedilol 2) monitor for hyperkalemia 3) after achieving maximal regression of LV dilatation, add clenbuterol & replace carvedilol with bisoprolol Management: - anticoagulation with warfarin to prevent ventricular thrombus [6]

Related

cardiac transplantation; heart transplant heart failure (HF) New York Heart Association classification of heart failure

General

surgical tissue replacement cardiac assist device; ventricular assist device

References

  1. Journal Watch 21(24):197, 2001 Rose EA et al for the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group. Long-term mechanical left ventricular assistance for end-stage heart failure. NEJM 345:1435, 2001 PMID: 11794191
  2. Birks EJ et al Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med 2006 355:1873 - Renlund DG & Kfoury AG When the failing, end-stage heart is not end-stage. N Engl J Med 2006, 355:1922
  3. Slaughter MS et al. for the HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009 Dec 3;361(23):2241-51. Epub 2009 Nov 17. PMID: 19920051 http://dx.doi.org/10.1056/NEJMoa0909938 - Fang JC. Rise of the machines - Left ventricular assist devices as permanent therapy for advanced heart failure. N Engl J Med 2009 Nov 17 PMID: 19920052 http://dx.doi.org/10.1056/NEJMe0910394
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018.
  5. Starling RC et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014 Jan 2; 370:33 PMID: 24283197
  6. Brock AS et al A Not-So-Obscure Cause of Gastrointestinal Bleeding N Engl J Med 2015; 372:556-561. February 5, 2015 PMID: 25651250 http://www.nejm.org/doi/full/10.1056/NEJMcps1302223
  7. Garbade J, Barten MJ, Bittner HB, Mohr FW. Heart transplantation and left ventricular assist device therapy: two comparable options in end-stage heart failure? Clin Cardiol. 2013 Jul;36(7):378-82 PMID: 23595910
  8. Mehra MR et al. A fully magnetically levitated circulatory pump for advanced heart failure. N Engl J Med 2016 Nov 16 PMID: 27959709 http://www.nejm.org/doi/10.1056/NEJMoa1610426
  9. Rogers JG et al. Intrapericardial left ventricular assist device for advanced heart failure. N Engl J Med 2017 Feb 2; 376:451. PMID: 28146651 Free Article http://www.nejm.org/doi/10.1056/NEJMoa1602954 - Hetzer R, Delmo Walter EM. Mechanical circulatory support devices - in progress. N Engl J Med 2017 Feb 2; 376:487 PMID: 28146667 http://www.nejm.org/doi/10.1056/NEJMe1613755
  10. Bansal N, Hailpern SM, Katz R et al. Outcomes associated with left ventricular assist devices among recipients with and without end-stage renal disease. JAMA Intern Med 2017 Dec 18; PMID: 29255896 - Thomas SS et al. The Renal Challenge With Left Ventricular Assist Device Therapy-When Enough Is Enough. JAMA Intern Med. 2017 Dec 18. PMID: 29255894
  11. Mehra MR, Goldstein DJ, Uriel N et al. Two-year outcomes with a magnetically levitated cardiac pump in heart failure. N Engl J Med 2018; 378:1386-1395. April 12, 2018. ePub Mar 11 PMID: 29526139 http://www.nejm.org/doi/10.1056/NEJMoa1800866
  12. Robertson J, Long B, Koyfman A. The emergency management of ventricular assist devices. Am J Emerg Med. 2016 Jul;34(7):1294-301. Review. PMID: 27162114
  13. Stokes MB, Bergin P, McGiffin D. Role of long-term mechanical circulatory support in patients with advanced heart failure. Intern Med J. 2016 May;46(5):530-40. Review. PMID: 26010730
  14. Stokes MB, Saxena P, Mariani JA et al Left Ventricular Assist Device (LVAD) as a Bridge to Recovery for Tachycardia-Mediated Cardiomyopathy. J Card Surg. 2015 Nov;30(11):871-3. dEpub 2015 Sep 8. PMID: 26350745
  15. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019