Correspondence
Six Years of Continuous Mechanical Circulatory Support
N Engl J Med 2006; 355:325-327July 20, 2006
- Article
To the Editor:
In 2001, a randomized trial comparing a pulsatile left ventricular assist device (LVAD) with medical therapy for end-stage heart failure reported a median survival advantage of 8.5 months for patients receiving the device.1 The patients' quality of life was limited by serious complications related to the LVAD. In 2000, we began a long-term observational study of circulatory support with a new, miniaturized axial-flow pump. At the time, there were important questions about the reliability of a blood pump powered by a rotary electric motor and the effects of diminished pulse pressure over time.
Our first patient was 61 years of age and had idiopathic dilated cardiomyopathy.2 While receiving maximal medical therapy, he was breathless at rest, with pitting edema to the thighs, ulcerated legs, and ascites. His left ventricular ejection fraction was less than 10 percent, with a cardiac index of 1.81 liters per minute per square meter of body-surface area and a maximal oxygen consumption of 5.7 ml per kilogram of body weight per minute during exercise. Cardiac transplantation was not recommended because of renal impairment (creatinine clearance, 38 ml per minute).
The Jarvik 2000 LVAD (Figure 1Figure 1
Left Ventricular Assist Device Implanted in the Left Ventricular Apex, with the Power Cable Connected to the Skull Pedestal.) was implanted directly into the apex of the dilated ventricle, unloading to the descending thoracic aorta. The performance of this device has been reported previously.3 A novel power-delivery system used a titanium pedestal that was screwed into the skull, so that rigid fixation, rich vascularity, and the absence of fat would help avoid power-cable infection (Figure 1).4 Afterload reduction was continued and warfarin was given, with the dose adjusted to maintain an international normalized ratio of 2.0 to 2.5.Six years later, the patient is in New York Heart Association class II with the same LVAD, despite very poor underlying left ventricular function. At a pump-rotor speed of 10,000 rpm, the resting cardiac output is 5.5 liters per minute with a mean blood pressure of 70 to 80 mm Hg and a pulse pressure of 10 to 15 mm Hg. The performance of the LVAD has remained unchanged since it was implanted.
The patient has a very active and productive life, including international air travel. Less than 5 percent of the follow-up period has been spent in the hospital. There have been no mechanical or thromboembolic complications, but external components have been exchanged because of wear and tear. The skull pedestal remains infection-free. Staphylococcal septicemia after cauterization for nosebleeds was successfully treated with antibiotics. The LVAD was not infected. Whole-body computed tomography has shown no evidence of thinning of the wall of the aorta, despite the diminished pulse pressure.
This case illustrates the potential long-term durability of the Jarvik 2000 axial-flow blood pump when used as an LVAD in a patient with advanced heart failure.
4 ReferencesStephen Westaby, M.D.
John Radcliffe Hospital, Oxford OX3 9DU, United KingdomO.H. Frazier, M.D.
Texas Heart Institute, Houston, TX 77225-0345Adrian Banning, M.D.
John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
adrian.banning@orh. nhs. uk 1
Rose EA ,Gelijns AC ,Moskowitz AJ , et al. Long-term mechanical left ventricular assistance for end stage heart failure. N Engl J Med 2001;345:1435-1443
Full Text | Web of Science | Medline2
Westaby S ,Banning AP ,Jarvik R , et al. First permanent implant of the Jarvik 2000 Heart. Lancet 2000;356:900-903
CrossRef | Web of Science | Medline3
Frazier OH ,Myers TJ ,Jarvik RK , et al. Research and development of an implantable axial-flow left ventricular assist device: the Jarvik 2000 Heart. Ann Thorac Surg 2001;71:Suppl 3:S125-S132
CrossRef | Web of Science | Medline4
Westaby S ,Jarvik R ,Freeland A , et al. Postauricular percutaneous power delivery for permanent mechanical circulatory support. J Thorac Cardiovasc Surg 2002;123:977-983
CrossRef | Web of Science | Medline
- Citing Articles (16)
Citing Articles
1
Duc Q. Nguyen, Vinod H. Thourani. (2010) Third-Generation Continuous Flow Left Ventricular Assist Devices. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 5:4, 250-258
CrossRef2
Joseph G. Rogers, Keith D. Aaronson, Andrew J. Boyle, Stuart D. Russell, Carmelo A. Milano, Francis D. Pagani, Brooks S. Edwards, Soon Park, Ranjit John, John V. Conte, David J. Farrar, Mark S. Slaughter. (2010) Continuous Flow Left Ventricular Assist Device Improves Functional Capacity and Quality of Life of Advanced Heart Failure Patients. Journal of the American College of Cardiology 55:17, 1826-1834
CrossRef3
Ana C Alba, Diego H Delgado. (2009) The future is here: ventricular assist devices for the failing heart. Expert Review of Cardiovascular Therapy 7:9, 1067-1077
CrossRef4
Mark Harrison, Anelechi Anyanwu, Sean P. Pinney. (2009) The Management of Stage D Heart Failure. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine 76:4, 404-414
CrossRef5
Hans Granfeldt, Bengt Peterzén, Laila Hübbert, Kjell Jansson, Henrik Ahn. (2009) A single center experience with the HeartMate II™ Left Ventricular Assist Device (LVAD). Scandinavian Cardiovascular Journal 43:6, 360-365
CrossRef6
Ranjit John. (2008) Current Axial-Flow Devices—the HeartMate II and Jarvik 2000 Left Ventricular Assist Devices. Seminars in Thoracic and Cardiovascular Surgery 20:3, 264-272
CrossRef7
Stephen Westaby. (2008) Destination therapy: time for real progress. Nature Clinical Practice Cardiovascular Medicine 5:8, 477-483
CrossRef8
Laila Hubbert, Bengt Peterzén, Stefan Traff, Birgitta Janerot-Sjoberg, Henrik Ahn. (2008) Axial Flow Pump Treatment During Myocardial Depression in Calves: An Invasive Hemodynamic and Echocardiographic Tissue Doppler Study. ASAIO Journal 54:4, 367-371
CrossRef9
Laura A. Coyle, Michele M. Martin, Sudha Kurien, Joel D. Graham, Colleen Gallagher, Marc A. Silver, Mark S. Slaughter. (2008) Destination Therapy: Safety and Feasibility of National and International Travel. ASAIO Journal 54:2, 172-176
CrossRef10
Naoyuki Yokoyama, Masaaki Suzuki, Hideo Hoshi, Katsuhiro Ohuchi, Tetsuo Fujimoto, Setsuo Takatani. (2007) Feasibility of a TinyPump System for Pediatric CPB, ECMO, and Circulatory Assistance: Hydrodynamic Performances of the Modified Pump Housing for Implantable TinyPump. ASAIO Journal 53:6, 742-746
CrossRef11
Miller, Leslie W., Pagani, Francis D., Russell, Stuart D., John, Ranjit, Boyle, Andrew J., Aaronson, Keith D., Conte, John V., Naka, Yoshifumi, Mancini, Donna, Delgado, Reynolds M., MacGillivray, Thomas E., Farrar, David J., Frazier, O.H., . (2007) Use of a Continuous-Flow Device in Patients Awaiting Heart Transplantation. New England Journal of Medicine 357:9, 885-896
Full Text12
Stephen Westaby. (2007) Lifetime Circulatory Support Must Not Be Restricted to Transplant Centers. Heart Failure Clinics 3:3, 369-375
CrossRef13
Manuel Prinz von Bayern, Martin Cadeiras, Mario C. Deng. (2007) Destination Therapy: Does Progress Depend on Left Ventricular Assist Device Development?. Heart Failure Clinics 3:3, 349-367
CrossRef14
Setsuo Takatani. (2007) Progress of Rotary Blood Pumps: Presidential Address, International Society for Rotary Blood Pumps 2006, Leuven, Belgium. Artificial Organs 31:5, 329-344
CrossRef15
Stavros G Drakos, Efstratios I Charitos, Serafim N Nanas, John N Nanas. (2007) Ventricular-assist devices for the treatment of chronic heart failure. Expert Review of Cardiovascular Therapy 5:3, 571-584
CrossRef16
Stephen Westaby. (2007) Surgery for Heart Failure: Now Something for Everyone?. Heart Failure Clinics 3:2, 139-157
CrossRef
