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Table of Contents
EDITORIAL  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 174-175
Heart transplantation in the era of continuous flow ventricular assist devices and the total artificial heart: Will new technologies surpass the gold standard?


1 Division of Cardiothoracic Anesthesiology, Mayo Clinic, AZ, USA
2 Division of Cardiothoracic Surgery, Mayo Clinic, AZ, USA

Click here for correspondence address and email

Date of Web Publication20-Aug-2011
 

How to cite this article:
Ramakrishna H, Pajaro OE. Heart transplantation in the era of continuous flow ventricular assist devices and the total artificial heart: Will new technologies surpass the gold standard?. Ann Card Anaesth 2011;14:174-5

How to cite this URL:
Ramakrishna H, Pajaro OE. Heart transplantation in the era of continuous flow ventricular assist devices and the total artificial heart: Will new technologies surpass the gold standard?. Ann Card Anaesth [serial online] 2011 [cited 2020 Jan 17];14:174-5. Available from: http://www.annals.in/text.asp?2011/14/3/174/83984


Since 1967, heart transplantation has had a tremendous impact on modern medicine and the surgical management of heart failure, with over 89,000 transplants performed worldwide over the last 40 years. [1] Every year over 5000 heart transplants take place in more than 225 centers around the world. In the US alone in 2010 there were 2333 heart transplants. [2] Recipient survival continues to improve and the most recent data available from the International Society of Heart and Lung Transplantation showed that in 2009, 1-year survival rates for men and women were 88% and 77.2%, respectively, and 5-year survival rates, 73.1% and 67.4%. [1] This survival improvement is the result of advances in multiple scientific and clinical disciplines including immunosuppressive therapy, the treatment of infectious complications, donor and recipient management, myocardial protection and postoperative management in the intensive care unit.

Despite the improvements in heart transplantation several problems persist. In the short term, a significant cause of mortality still results from graft failure, rejection and infectious complications and in the long term, the recipients are at continued risk for developing malignancies and allograft coronary vasculopathy, the latter contributing to more than 50% of the mortality after 5 years. [3] Furthermore, in the western world more than 20 million patients suffer from end-stage heart failure, an average prevalence of 2-2.5% overall, increasing to 10% in octogenarians. [4] In the US alone, nearly 100,000 patients suffer from advanced heart failure. Clearly, heart transplantation can only be accessible to a small percentage of those in congestive heart failure. Thus, it is understandable that enormous worldwide effort and funding has gone into the development of mechanical circulatory support devices. The other key factor behind the impetus to develop the "perfect" replacement for the failing heart, is the worldwide shortage of donor hearts (arguably a result of improvements in automobile safety technology, trauma prevention, as well as medical, surgical and ICU trauma management- all of which have significantly reduced the potential organ donor pool). The donor shortage situation is not likely to improve in the foreseeable future. In the US alone, the situation is dire for patients with congestive heart failure, with only a small fraction of patients able to undergo heart transplantation.

Advances in mechanical circulatory support have been steady over the last 40 years and have occurred concomitantly with advances in heart transplantation. The progress has been both technological and conceptual. While the use of mechanical pumps had occurred prior to the 1980s, the implantation of the Jarvik 7 in 1982 in the retired dentist, Barney Clark and his unfortunate demise with postoperative strokes brought the concept of mechanical circulatory support, along with its potential problems to the private home, the media and the government. [5] Ethical questions were raised, who would pay, who would want to be attached to a machine, have we gone too far? Nonetheless, the use of mechanical support has extended way beyond its use as a bridge for those awaiting transplant to its use in lieu of transplant either because the patient does not qualify for a transplant or because the patient does not desire a transplant. The concept of destination therapy arose over the last 5-6 years and the implementation grow rapidly with the success of continuous flow pumps. [6] While it initially seemed that destination therapy would be primarily for the elderly patient or the patient with an absolute medical contraindication for transplantation (e.g., cancer), some younger patients gradually began to prefer mechanical circulatory support and did not wish to be considered for transplantation.

The improvements in outcomes in the use of mechanical circulatory support over the last decade have dramatically increased the appeal to both physicians and patients. Survival has increased from 10% at 2 years to almost 60% in a recent study published in 2009. [7] Thromboembolic and hemorrhagic events have decreased. The likelihood of a device failure has dropped significantly. Continuous flow pumps are smaller and lighter with easier to manage power sources that have made the device less imposing than the image created by the original media photos of the Jarvik 7. The ability to electively schedule a device implant provides the patient with a certainty not available to transplant recipients. Newer data continues to emerge reflecting the many advantages of continuous axial flow pumps over the older generation pulsatile flow devices. [7],[8]

Of course, device implantation is not risk-free. Perioperative and postoperative bleeding, thrombotic events and infection are still an issue. The continuous flow pumps also increase the risk of gastrointestinal bleeding and have been shown to affect von Willebrand's factor. [9] Furthermore, the acute risk of right heart failure and the long-term morbidity of right heart dysfunction in a significant number of patients who undergo a left ventricular assist device alone are becoming increasingly evident as major limitations of the continuous flow pumps. Thus, renewed interest has emerged in developing a continuous flow biventricular support system [10],[11] and in the use of a total artificial pulsatile heart, as offered to Barney Clark, in order to address the morbidity associated with right heart failure.

The growing availability and the potentially diminishing cost of mechanical circulatory support devices will allow for more widespread use than that offered by the limited supply of donor hearts and will allow for the implementation of clinical trials and device improvements at a scale unreachable by heart transplantation. Furthermore, the ability of patients to adapt to living with an artificial heart pump makes mechanical circulatory support likely to minimize heart transplantation in the future. One can expect to see a proliferation of complex, implantable devices that will be smaller in scale and more robust with each generation.

 
   References Top

1.Stehlik J, Edwards LB, Kucheryavaya AY, Aurora P, Christie JD, Kirk R, et al. The Registry of the International Society for Heart and Lung Transplantation: Twenty-seventh official adult heart transplant report--2010. J Heart Lung Transplant 2010;29:1089-103.  Back to cited text no. 1
    
2.Available from: http://www.optn.transplant.hrsa.gov/latestData/rptData.asp. [Last accessed on 2011 Jun 16].  Back to cited text no. 2
    
3.Kirklin JK, Pambukian SV, McGiffin DC, Benza RL. Current outcomes following heart transplantation. Semin Thorac Cardiovasc Surg 2004;16:395-403.  Back to cited text no. 3
    
4.Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Executive summary: Heart disease and stroke statistics--2010 update: A report from the American Heart Association. Circulation 2010;121:948-54.  Back to cited text no. 4
    
5.Wallis C. Death of a gallant pioneer. Barney Clark: 1921-1983. Time 1983;121:62-3.  Back to cited text no. 5
    
6.Sheikh FH, Russell SD. HeartMate® II continuous-flow left ventricular assist system. Expert Rev Med Devices 2011;8:11-21.  Back to cited text no. 6
    
7.Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009;361:2241-51.  Back to cited text no. 7
    
8.Fang JC. Rise of the machines--left ventricular assist devices as permanent therapy for advanced heart failure. N Engl J Med 2009;361:2282-5.  Back to cited text no. 8
    
9.Uriel N, Pak SW, Jorde UP, Jude B, Susen S, Vincentelli A, et al. Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. J Am Coll Cardiol 2010;56:1207-13.  Back to cited text no. 9
    
10.Saito S, Sakaguchi T, Sawa Y. Clinical report of long-term support with dual Jarvik 2000 biventricular assist device. J Heart Lung Transplant 2011;30:845-7.  Back to cited text no. 10
    
11.Saito S, Sakaguchi T, Miyagawa S, Yoshikawa Y, Yamauchi T, Ueno T, et al. Biventricular support using implantable continuous-flow ventricular assist devices. J Heart Lung Transplant 2011;30:475-8.  Back to cited text no. 11
    

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Correspondence Address:
Harish Ramakrishna
5777 East Mayo Blvd, Phoenix, Phoenix, AZ 85054
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.83984

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