Left ventricular assist device implantation in high risk destination therapy patients: an alternative surgical approach.

Left Ventricular Assist Device (LVAD) for Destination Therapy (DT) is an established therapy for end stage heart failure patients who are not transplant candidates. Many DT patients requiring LVADs have had prior open heart surgery, the majority of whom had prior sternotomy. In addition, DT patients tend to be older and more likely to have more significant co-morbidities than their Bridge-To-Transplant (BTT) counterparts. As such, placement of an implantable LVAD in DT patients can be technically hazardous and potentially prone to more perioperative complications. The purpose of this report is to describe an alternative implantation approach for the implantation of the Heartmate II™ LVAD in high risk DT patients.

Heartmate II™ device placement five years following ACORN CorCap™ device implantation.

Left ventricular assist device (LVAD) for destination therapy (DT) is an established therapy. More patients requiring LVADs have had prior open heart surgery, the majority of whom had prior sternotomy. As such, placement of an implantable LVAD in a redo setting can be hazardous. This report describes the implant of a Heartmate II™ LVAD in a patient with a prior ACORN CorCap™.

Cardiogenic shock associated with loco-regional anesthesia rescued with left ventricular assist device implantation.

A healthy 53 year old man developed profound cardiogenic shock following instillation of bupivacaine-lidocaine-epinephrine solution as a locoregional anesthetic for elective outpatient shoulder surgery. Intubation, resuscitation, and transfer to the nearby hospital were done: echocardiography showed profound biventricular dysfunction; cardiac catheterization showed normal coronary arteries. Despite placement of an intra-aortic balloon pump and intravenous vasoactive drugs, the patient remained in shock. Stabilization was achieved with emergent institution of cardiopulmonary bypass and placement of a temporary left ventricular assist device (LVAD). Twenty-four hours later, cardiac function normalized and the LVAD was removed. The patient was discharged five days later and remained with normal heart function in three-year follow-up.

Hybrid ventricular assist device: Heartmate XVE LVAD and Abiomed AB5000 RVAD.

The need for a right ventricular assist device following an implantable left ventricular assist device creates a complex situation for the surgeon, nursing staff, and the patient. The purpose of this report is to describe the rationale, technical, and perioperative issues of a hybrid ventricular assist device consisting of a Heartmate XVE (Thoratec, Inc., Pleasonton, CA) left ventricular assist device and Abiomed AB5000 right ventricular assist device (Abiomed, Inc., Danvers, MA).

Argatroban as a primary or secondary postoperative anticoagulant in patients implanted with ventricular assist devices.

BACKGROUND: We describe our experience with argatroban as a primary or secondary postoperative anticoagulant to heparin in patients receiving ventricular assist devices. METHODS: This is a retrospective review of all Abiomed (BVS5000, AB5000) and Thoratec (PVAD and IVAD) ventricular assist devices from May 2003 through May 2006 at a single institution. Postoperatively, patients received either heparin or argatroban as their anticoagulant. Patients in whom heparin-induced thrombocytopenia was suspected or confirmed were converted from heparin to argatroban. RESULTS: There were 33 Abiomed and Thoratec ventricular assist devices implanted. Thirteen patients received heparin as their primary postoperative anticoagulant; 8 of the 13 were converted to argatroban as a secondary anticoagulant (hep-arg), and 5 patients remained with heparin as their only anticoagulant. Twenty patients received argatroban as their primary and only postoperative anticoagulant. Thrombocytopenia occurred in 26 patients (79%) overall, 16 (80%) with argatroban only, 6 (75%) with hep-arg, and 4 (80%) with heparin only. Thromboembolic events occurred in 5 patients (15%) overall, 3 (15%) with argatroban only, 1 (13%) with hep-arg, and 1 (20%) with heparin only. Postoperative bleeding requiring reexploration occurred in 5 patients overall (15%), 1 with argatroban only (5%), 3 (38%) with hep-arg, and 1 (20%) with heparin only. Enzyme-linked immunosorbent assay heparin-induced thrombocytopenia tests were positive in 7 patients overall (21%), 5 (25%) with argatroban only, 2 (25%) with hep-arg, and 0 (0%) with heparin only. CONCLUSIONS: Argatroban is a comparable primary or secondary anticoagulant to heparin postoperatively in patients receiving ventricular assist devices.

Postcardiotomy cardiogenic shock: the role of ventricular assist devices.

Postcardiotomy cardiogenic shock (PCCS) remains a life-threatening complication of cardiac surgery. Although survival rates have doubled in the past decade, PCCS continues to result in significant morbidity and mortality. Factors contributing to improved outcomes include early recognition of shock, early application of ventricular assist device (VAD) technology in cases of refractory shock, better technology, better surgical application (less technical error), application of treatment protocols, and assignment of management to specially trained personnel. A systematic approach to the management of PCCS can facilitate consistent care. This same approach can be applied to all forms of shock. VAD technology provides an opportunity for survival when other medical and surgical options fail.