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 d evice implantation in lieu of transplantation could be addressed throu gh the creation of appropriately designed trials. Our medium-term expe rience with both pneumatically and electrically powered ThermoCardiosy stems LVADs is presented to outline the benefits and limitations of de vice support in lieu of transplantation. Methods and Results Detailed records were kept prospectively for all patients undergoing LVAD inser tion. Fifty-eight LVADs were inserted over 5 years, with a survival ra te of 74%. Mean patient age was 50 years, and duration of support aver aged 98 days. Although common, both preexisting infection and infectio n during LVAD support were not associated with increased mortality or decreased rate of successful transplantation. Thromboembolic complicat ions were rare, occurring in only three patients (5%) despite the abse nce 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 ode th ird of patients and was managed in a small percentage by right ventric ular assist device (RVAD) support and/or inhaled nitric oxide therapy. There were no serious device malfunctions, but five graft-related hem orrhages resulted in two deaths. Finally, a variety of noncardiac surg ical procedures were performed in LVAD recipients, with no major morbi dity and mortality. Conclusions Over all, our medium-term experience w ith implantable LVAD support is encouraging. Although additional areas of investigation exist, improvements in patient selection and managem ent together with device alterations that have reduced the thromboembo lic incidence and facilitated patient rehabilitation lead us to believ e that a prospective, randomized trial is indicated to study the role that LVADs may have as an alternative to medical management.