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|Year : 2009
: 12 | Issue : 2 | Page
|Adult cardiac transplantation: A review of perioperative management (Part - II)
Harish Ramakrishna1, Dawn E Jaroszewski2, Francisco A Arabia2
1 Department of Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA
2 Division of Cardiovascular and Thoracic Surgery (D.E.J., F.A.A.), Mayo Clinic, Phoenix, Arizona, USA
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|Date of Web Publication||21-Jul-2009|
| Abstract|| |
Heart transplant is the definitive therapy for end-stage heart failure. This two part review article focussed first on the perioperative management of patients for heart transplantation. This part II will be a comprehensive review of the current status of mechanical assist device therapy for surgical management of the patient with refractory end-stage heart failure.
Keywords: Artificial heart, heart failure, heart transplantation, anesthetic management, left ventricular assist device, right ventricular assist device
|How to cite this article:|
Ramakrishna H, Jaroszewski DE, Arabia FA. Adult cardiac transplantation: A review of perioperative management (Part - II). Ann Card Anaesth 2009;12:155-65
|How to cite this URL:|
Ramakrishna H, Jaroszewski DE, Arabia FA. Adult cardiac transplantation: A review of perioperative management (Part - II). Ann Card Anaesth [serial online] 2009 [cited 2021 Sep 28];12:155-65. Available from: https://www.annals.in/text.asp?2009/12/2/155/53441
| Cardiac Transplantation and Mechanical Assist Device Therapy|| |
Orthotopic heart transplant is recognized as the best therapy for end-stage congestive heart failure.  However, under the current procurement system, approximately 15 to 30% of potential cardiac recipients die while waiting for a donor heart. , This discrepancy between possible recipients and available donors generates a realistic need for circulatory assist devices for cardiac support and replacement. 
Mechanical circulatory assistance was initially used for post-cardiotomy cardiogenic shock, ,,, but more recently it has been used for temporary cardiac support, bridge to recovery (BTR), until a donor heart becomes available for transplantation or "bridge to transplantation" (BTT). ,,,,,, Destination therapy (DT) refers to the use of some of these pumps permanently to support the heart in patients who are not transplant candidates. The use of all these devices has continued to increase in recent years  and DT could become a major area where these devices are utilized. This section discusses patient selection, indications for use, the spectrum of devices currently used for cardiovascular assistance, and some of their complications.
Patient selection is probably the most important factor in determining success with mechanical circulatory assistance. Early experience with the use of post-cardiotomy devices for cardiac recovery showed that patients younger than 60 years had a survival rate of 21-31%, patients older than 60 years had a survival rate of 12%, and patients over 70 years had a survival rate of 6%. ,, Other factors contributing to successful outcomes include careful selection of assist device and the skill, experience, and judgment of the implanting team. [Table 1] lists basic criteria used as guidelines for placement of ventricular assistance. These guidelines include, essentially, a definition of cardiogenic shock. When criteria for placement of ventricular assistance are met, prompt intervention is important as prolonged hypotension (greater than 12 hours) is associated with multi-system failure and poor recovery.  Measurement of cardiac output and atrial pressure are necessary to assess the patient's need for a device. These parameters are also very helpful in the immediate post-operative period, especially after implantation of a uni-ventricular device.
The necessity for biventricular versus uni-ventricular support must be addressed very early in the evaluation process. Patients who need a bridge to transplantation may be supported with uni-ventricular or bi-ventricular support depending on preoperative hemodynamic parameters. In general, those who have low right atrial pressure, normal or slightly elevated pulmonary vascular resistance and no ventricular arrhythmias may benefit from left ventricular support only. Approximately 20-25% of patients who receive left ventricular support alone may require right ventricular assistance. , [Table 2] summarizes current criteria used to differentiate between the need for uni-ventricular or bi-ventricular support. The need for bi-ventricular assist device should raise the question if a total artificial heart (TAH) is needed instead.
Trans-esophageal echocardiography (TEE) has been found to be extremely useful during implantation of devices because it can immediately provide information regarding proper orientation of the device so it can function under optimal conditions. TEE is also helpful in evaluating right ventricular function when only a left ventricular assist device is utilized. It also provides useful assistance in removing air from the heart or atria after implantation and prior to discontinuing cardiopulmonary bypass. It is very useful when a TAH is placed to verify that there is no compression of the pulmonary veins and cavae.
Ventricular assist devices
A large number of devices have been invented in the last few decades. Many have found themselves not leaving the drawing board while others have made it to laboratory experimentation [Table 3]. The ones presented here are those that have made it to the clinical arena or offer a great deal of hope.
Pulastile paracorporeal and intracorporeal pumps
These include the Thoratec pVAD, Abiomed BVS 5000 and AB 5000, The Novacor LVAS, Heartmate 1 and Thoratec IVAD
Paracorporeal and intracorporeal pumps provide univentricular or biventricular pulsatile flow. A system of 2 or 4 cannulae provides inflow and outflow to the blood pumps. The most commonly used devices have been Thoratec (Berkeley, CA) and Abiomed (Danvers, MA). These devices are commercially available.
Thoratec ventricular assist device
The Thoratec ventricular assist device (VAD), (Berkeley, CA) is a pneumatically driven prosthetic ventricle placed paracorporeal (PVAD) [Figure 1] or intracorporeal (IVAD) [Figure 2].
This system has been used successfully as a bridge to recovery or transplantation.  The inflow cannula is placed in the right or left atrium. Unidirectional mechanical valves are located in the inflow and outflow ports of the device. The outflow conduits are anastomosed to the ascending aorta or pulmonary artery via a Dacron graft. However, superior left device filling is obtained if the left pump inflow cannula originates from the patient's left ventricular apex. A polyurethane sac divides the blood chamber from the air chamber within the prosthetic ventricle. The stroke volume from each para-corporeal ventricle is about 65 ml. These devices are capable of delivering flows up to 6.5 L/min. The pneumatic drives connect to a console that is a few feet from the patient and the system can be triggered in synchronous or asynchronous mode.
The Thoratec PVAD and IVAD can be installed in different configurations including as a single VAD or in a biventricular configuration (BIVAD). The left ventricular pump can be placed as a bridge to recovery by placing a left atrial cannula in the left atrial appendage or by placing it in the intra-atrial groove. The outflow cannula is anastomosed to the ascending aorta. This can sometimes be accomplished without cardiopulmonary bypass. When the device is intended as a bridge to transplant, it is recommended that the inflow cannula to the device be anastomosed to the left ventricular apex. A special cannula is designed for this purpose. It is in this configuration that the maximal output is obtained for this particular device. CPB is required when the left ventricular apical cannula is used. When a right sided device is also used, the inflow cannula is placed in the right atrium or right ventricle. The outflow cannula is anastomosed to the pulmonary artery. All cannulae are placed in the upper abdomen and tunnelled through the skin and fascia into the pericardial space [Figure 3].
The system is de-aired. If cardiopulmonary bypass is utilized, the single VAD or BIVAD's are allowed to take over the circulation by increasing the rate and decreasing the CPB flow rate. If cardiopulmonary bypass is not utilized, then the single VAD or BIVAD's are allowed to take over the circulation.
Abiomed BVS 500 system
The Abiomed BVS 5000 System is also a para-corporeal, pulsatile, pneumatic device that can provide short-term uni-ventricular or biventricular support. Each blood pump consists of 2 polyurethane chambers that are separated by tri-leaflet polyurethane valves. Blood flows continuously through both chambers during systole and during diastole by gravity from the patient's atrium into the first chamber of the blood pump. From here, it flows passively across the inlet valve into the active ventricle-like chamber where it is pneumatically propelled into the patient's great vessels. The pumps are operated by a console that determines the pulsatile rate and systole/diastole ratio based on the compressed air flow into and out of the chambers. The system maintains a stroke volume of 82 mL and was designed as a support system for hearts, which have sustained reversible damage, particularly in failure to wean from cardiopulmonary bypass. The Abiomed can provide flows up to five L/min. However, it has also been used as a bridge to transplantation. ,,
Abiomed AB 5000
Abiomed AB 5000 is another short-term support system that can provide left, right or biventricular support for patients whose hearts have failed but have the potential for recovery. The device can also be used as a bridge to definitive therapy. The pump contains a membrane and two tri-leaflet valves. Cannulae are placed in the heart and connected to the pump. These fill with blood by gravitational force and by vacuum assistance from the drive console. The cannulae and drive console are the same as those used for the ABIOMED BVS 5000. The AB5000 can provide flow rates of up to 6 L/min.
The Novacor (Division of Baxter Health Care Co., Oakland, CA) and the HeartMate I (Thoratec, Pleasanton, CA) represent implantable uni-ventricular assist devices that provide pulsatile assistance to the failing left ventricle. With evolving technology these products are being improved and introduced as newer generation models that are smaller and provide easier patient mobility. The Novacor is an electrically driven pump that energizes a solenoid which moves a dual-pusher plate to propel blood into the aorta [Figure 4]. Its main application has been as a bridge to cardiac transplantation, , but it has also been used to support patients in profound cardiogenic shock after cardiac surgery. The Novacor device is implanted in the left upper quadrant of the abdomen and weighs approximately 3.3 kg. The inflow to the device comes via a Dacron conduit anastomosed to the apex of the left ventricle. The outflow is via a similar conduit that is usually anastomosed to the ascending aorta or, occasionally, the abdominal aorta. 
The surgical implantation of the Novacor LVAS requires cardiopulmonary bypass. Bioprosthetic (porcine) inflow and outflow valve conduits maintain unidirectional flow. The power line and vent are placed subcutaneously and exit the patient in the right lower quadrant of the abdomen. A series of sensors are attached to the pump mechanism and exit the body to connect to a console where information about filling, stroke volumes, pump rate and energy usage are displayed for analysis. This device can provide flows up to 8 L/min.
The HeartMate I assist device is a totally implantable, pneumatically or electrically driven dual-chamber pump in titanium housing. The HeartMate is implanted through a median sternotomy that extends to the umbilicus. Cardiopulmonary bypass is instituted from the right atrium to the ascending aorta.
A polyurethane flexible diaphragm divides the air and blood chambers. The metallic side of the blood chamber is made of sintered titanium microspheres. This surface promotes lining of the device with the patient's own blood products to minimize clot formation.  This VAD is positioned intra-abdominally in the left upper quadrant of the abdomen or preperitoneal , without entering the abdomen. The inlet Dacron conduit is anastomosed to the apex of the left ventricle and the outlet conduit goes to the aorta. Porcine valves, located at the inlet and outlet of the device, provide unidirectional flow. The pneumatic drive line is positioned subcutaneously and exits the skin at a distance from the device to connect to the external console. This device can generate up to eight L/min of blood flow. This device was the first one approved by the Food and Drug Administration (FDA) as a bridge to heart transplantation and destination therapy.
The advantage of these two devices is that the patients can be sent home while waiting for a heart transplant. This approach has shown a reduction in the total cost for the therapy. It also sets the patient in a more familiar environment (B, C).
Axial pumps: (HeartMate II, Micromed DeBakey, Jarvik 2000)
The HeartMate II is a rotary pump with axial flow design that represents a second generation of implantable assist devices designed to be a small, portable and reliable for long-term outpatient left ventricular support [Figure 5]. It is FDA approved for bridge-to-transplantation.  The major advantage of the HeartMate II is the small size and weight. The system consists of an internal blood pump with a percutaneous lead that connects the pump to an external system driver and power source [Figure 6]. Cardio-pulmonary bypass without arrest is required for placement. The pump is implanted preperitoneal below the left costal margin and under the rectus abdominus muscle. The inflow cannula is placed into the left ventricular apex and tunnelled through the diaphragm at the costophrenic angle into the preperitoneal pocket. The outflow cannula is tunneled back under the sternum and through the diaphragm to the ascending aorta. The result of the initial pilot trial of the HeartMate II showed efficacy for hemodynamic improvement and organ recovery. ,, In the outpatient setting, it has provided excellent, reliable support with significant improvement in functional activity, ease of use, and comfort related to the small, compact size. The HeartMate II is currently undergoing further clinical investigation in trials including multiple centers to assess its efficacy for destination therapy.
The MicroMed DeBakey (MicroMed) VAD is a left ventricular miniaturized electromagnetic titanium pump developed by famed heart surgeons Dr. Michael E. DeBakey and Dr. George P. Noon in collaboration with the National Aeronautics and Space Administration (NASA). Formerly the NASA/DeBakey VAD, it was the first fully implantable second-generation assist device. The first human implantation was performed in Europe in 1998 and in the USA in 2000.  It is a miniaturized VAD capable of pumping up to 10L of blood per minute and is the only device with a flow probe which is positioned on the VAD's outflow cannula to measure actual pump flow.  The system implants into the left ventricular apex and an outflow conduit graft is anastomosed to the ascending aorta. Full cardiopulmonary bypass is required to place the device. Either a median sternotomy or left thoracotomy approach can be used for placement.
Jarvik 2000 is an electrically powered, valveless axial-flow blood pump that provides continuous flow from the left ventricle to the aorta [Figure 7].
Electrical power rotates a single moving part, the vaned impeller. The impeller is a neodymium-iron-boron magnet welded inside a titanium shell. This device is only 2.5 cm wide and 5.5 cm long and is unique in that it can be placed within the left ventricle and no inlet cannula is needed. Use of cardiopulmonary bypass is not necessary depending on implantation technique.  The device can be implanted through a left thoracotomy from the apex of the left ventricle to the descending aorta, through a median sternotomy from the apex of the left ventricle to the ascending aorta or through the diaphragmatic surface of the left ventricle with the outlet graft sewn to the supraceliac aorta via an extra thoracic route. , The Jarvik 2000 left ventricular assist device (LVAD) has been effective in long-term support of destination and bridge-to-transplant patients. Patients have been sustained for more than 400 days with this device.  The pump best performs as a booster to native ventricular function. It is associated with minimal infections and is an excellent option for long-term survival for patients with left ventricular failure. The normal operating range for the control system is 8,000 to 12,000 revolutions per minute, which will generate an average pump flow rate of five liters per minute.
Centrifugal: Impella recover, tandem heart
The Impella Recover device and the Tandem Heart differ from other assist devices in that they can be inserted either by cardiovascular surgeons in the operating room or by cardiologists in the cardiac catheterization laboratory.
Impella recover device
The Impella Recover device is a low-cost micro-axial assist device that pumps three to four L/min and is associated with a low complication rate. It improves survival in patients with low-output syndrome if the patient's heart is able to contribute at least 1 L/min to the overall cardiac output. It can be inserted retrograde into the left ventricle across the aortic valve through a 10-mm vascular graft sewn to the ascending aorta or through a femoral approach in the cardiac catheterization laboratory. It has a survival benefit in patients with post-cardiotomy failure that still retain some pumping function. ,
The TandemHeart™ Percutaneous Ventricular Assist Device (pVAD) has been used in postcardiotomy cardiogenic shock patients (those who have developed heart failure as a result of heart surgery or a heart attack) and as a bridge to a definitive therapy. The TandemHeart pVAD provides short-term support from a few hours to up to 14 days. The TandemHeart pVAD is a continuous-flow centrifugal assist device placed outside the body (extracorporeally). Cannulas are inserted percutaneously through the femoral vein and advanced across the intra-atrial septum into the left atrium [Figure 8].
The pump withdraws oxygenated blood from the left atrium and propels it by a magnetically driven, six-bladed impeller through the outflow port, and returns it to one or both femoral arteries via arterial cannulas. The pump weighs eight ounces and is capable of delivering blood flow up to 4.0 L/min. The system provides localized anticoagulation to the blood inside the pump, reducing the need for systemic anticoagulation.
Total artificial hearts: Cardiowest TAH, abiomed abioCor
The TAH provides complete support of the circulation with replacement of the native heart. Although this device has been used to provide permanent support, its most important role is to serve as a bridge to cardiac transplantation. These devices are the CardioWest 70 TAH and the Abiomed AbioCor. The first clinical use of an artificial heart was performed in 1969 by Cooley  when he implanted the Liotta Heart to support a patient for 64 hours until a donor heart became available for transplant. Use of the TAH as a permanent device was initiated by DeVries in 1982, when he implanted a Jarvik-7 in a patient,  who survived 112 days. The first successful use of the Jarvik-TAH as a bridge for cardiac transplantation was performed in 1985. 
Since 1991, the Jarvik-7 with 70-ml ventricles, has been renamed the CardioWest C-70 TAH.  The CardioWest (SynCardia Systems, Inc., Tucson, AZ) is a biventricular orthotopic pneumatically driven pulsatile TAH that is Food and Drug Administration (FDA) approved as a bridge-to-heart transplantation. Two separate prosthetic ventricles with Medtronic-Hall mechanical valves take the place of native ventricles and provide unidirectional flow [Figure 9]. Blood and air are separated by a four-layer, segmented polyurethane diaphragm which retract during diastole and is displaced forward by compressed air during systole to propel blood out of the prosthetic ventricle. The TAH can provide flows up to 15 L/min. However, it is usually used to provide flows at six to eight L/min. 
Conduits in the transabdominal wall connect to drivelines and an external console. The device controller provides adjustment of the heart rate, systolic duration and drive line pressures for each of the ventricles. Patients are able to ambulate within the confines of the hospital and participate in rehabilitation exercises as the console is mobile. Development of a portable console worn by the patient is being tested and is expected to be available next year. This advancement will allow increased mobility and potential discharge home from the hospital.
The AbioCor (Abiomed Inc., Danvers, MA) is the first completely self-contained electrohydraulic TAH. The AbioCor operates on both internal and external lithium batteries. The internally implanted battery is continually recharged from an external console or battery pack through a trans-cutaneous energy transmission system (TETS) that provides the power across the skin.  No drivelines are required that penetrate the skin. The internal batteries have approximately 20 minutes of operating time before recharging is needed. The pump weighs only about two pounds and consists of artificial ventricles containing valves and a motor-driven hydraulic pump. An electronic monitoring system in also implanted with controls the pumping speed of the TAH based on the physiologic needs of the patient. Approval under humanitarian device exemption was given by the FDA for use as a destination therapy in 2006.
Results of devices used for bridge to transplantation
For over two decades, multiple types of circulatory devices in a state of continual evolution have been utilized worldwide. As of 2008, thousands of devices have been implanted worldwide with the intent of bridging terminal patients in severe congestive heart failure to recovery, heart transplantation, or destination. The majority of patients underwent implant due to critical cardiogenic shock. The most common etiology among the patients requiring a bridge was idiopathic cardiomyopathy followed by ischemic cardiomyopathy. Implantation by age groups was 0-18 (3.4%), 19-39 (18.5%), 40-59 (49.3%), 60-79 (28.4%), 80+ (0.1%) [Figure 10],[Figure 11],[Figure 12]. 
| Discussion|| |
The success rates of all the devices demonstrate their efficacy in bridging a patient-to-heart transplantation. The individual rates range between 81-94%.  The fact that the rates are similar should serve to improve the selection criteria for the use of devices. The patient needs dictate what device should be utilized.
Protocols for anti-coagulation differ among institutions using mechanical assist devices, mainly because no single regimen seems to be more effective than the others. , Many agents have been used at different times after implantation and in varying combinations. These agents include: Low molecular dextran, heparin, warfarin, aspirin, and dipyridamole. A typical regimen at our institution includes the use of dextran at 25-50 cc/hr and dipyridamole at 100 mg q6h on the first post-operative day. Heparin by continuous intravenous infusion to maintain the partial thromboplastin (PTT) at 50-60 seconds is started when postoperative bleeding is controlled, usually on the second or third postoperative day. At the time heparin is started, dextran is discontinued. The patient is maintained on heparin and dipyri damole unless a relatively long implant time is anticipated. In this case, warfarin is favored over heparin with maintenance of the prothrombin time (PT) at approximately 18 to 22 seconds (INR 2.5 to 3.5). If there is clinical evidence for thromboembolism, aspirin is added at a dose of 81-325 mg/day.
More recently, for patients implanted with TAH's, the protocol includes the use of pentoxifylline 1200 mg/day in combination with heparin, warfarin, aspirin, and dipyridamole to stabilize platelet function and to balance the different coagulation pathways.  In order to monitor the effectiveness of anticoagulation therapy, in addition to the usual PT and PTT, factor X assay, fibrinogen, fibrin degradation products, platelet count, bleeding time, and in vitro platelet aggregability in response to four different stimulators (adenosine, adrenaline, collagen and arachidonic acid) are studied. The use of thromboelastography, probably the best available indicator of overall coagulation mechanisms, and the calculation of the thrombodynamic potential index give a measurement of the coagulability of blood, by examining the rapid phase of clot formation. 
Common complications encountered with the use of circulatory assist devices include bleeding, thromboembolism, infection, hemolysis and multi-organ failure.
Bleeding can be significant at the time of placement of a circulatory assist device, particularly if cardio-pulmonary bypass has been used for a prolonged period of time. Activation of platelets and the coagulation system by exposure of the blood to artificial surfaces and turbulent flow patterns may lead to a severe coagulopathy.  Control of bleeding from suture lines, conduits and raw surfaces as a result of deficiencies in the coagulation system can be a significant problem. The bleeding time becomes greater than 30 minutes after two hours of cardiopulmonary bypass  due to platelet dysfunction. Depending upon the extent of platelet damage, normalization of function may occur 30 minutes after termination of cardiopulmonary bypass. Prolonged bleeding time with a platelet count above 100,000 indicates platelet dysfunction that may require exogenous platelet administration.
Desmopressin, a synthetic analogue of the hormone vasopressin has been useful in augmenting platelet function. , Its mode of action is mediated by Factor VIII complex and therefore, adequate levels of Factor VIII are required. A decrease in bleeding time may be measured at 30-90 minutes following administration. Bleeding may also become a significant problem at the time of device explantation. Dense adhesions between the device and the intrathoracic organs may cause diffuse hemorrhage. The use of Amicar in the pharmacologic armamentarium during implantation and/or explantation of devices might decrease bleeding significantly and increase survival. The anesthetic management for assist device explantation can be very challenging. The key predictors of complexity are: Duration of device insertion, type of device, patient co-morbid conditions and patient coagulation status. The anesthesiologist must be prepared for severe bleeding and the consequent possibility of rapid volume transfusion into a right ventricle that may be physiologically not ready. A smooth transition from device to inotropes off cardiopulmonary bypass mandates compulsive attention to hemodynamic status, appropriate vascular access, pharmacologic support of biventricular function as well as optimization of oxygenation and ventilation. Reducing pulmonary vascular resistance using a combination of inotropes, pulmonary vasodilators, inhaled nitric oxide and phosphodiesterase inhibitors is critical. One must also keep in mind the possibility of return to cardiopulmonary bypass and re-insertion of assist device and/or intra-aortic balloon counter-pulation or Impella as adjunctive therapy.
The formation of macroscopic thrombus in circulatory assist devices is commonly seen at explantation even when the patient has had "adequate anti-coagulation." Many of the devices have internal sites that may provide a nidus for the formation of thrombus. ,, Other factors that appear to be involved in the development of thrombus within assist devices are a low or reduced blood flow and infection. The low flow state and the contact of blood with an artificial surface accelerate thrombus formation. Infection can lead to a hyper-coagulable state with activation of inflammatory cells and mediators leading to the formation of thrombus.
Embolic complications can occur at any time. The brain is by far the most sensitive and reported organ affected by thrombo-embolism. However, irreversible neurologic damage is uncommon; transient ischemic attacks are more frequent. Embolism to the kidneys, ophthalmic artery, lungs and heart via the coronary arteries has also been documented.
Patients who need circulatory assistance are at risk for developing infections not only because of the presence of a large foreign body, but also because they are often debilitated and malnourished. Prophylactic antibiotics during the peri-operative period are routinely used. The longer the device remains implanted, the higher the incidence of infection. Thrombosis, thrombo-embolism and infection are more common beyond 30 days of support and these complications may be interrelated.  Infection at the drive site is the most common. Pneumonia and mediastinitis are the most prevalent infections encountered. ,, Other types include peri-device infection involving not only the device and its inflow and outflow conduits, but also the drive lines. These infections require systemic antibiotics and surgical debridement.
Hemolysis is often seen in patients who have been on cardiopulmonary bypass for an extended period of time. Chronic hemolysis can be associated with anaemia requiring transfusions which may sensitize a potential transplant patient to tissue antigens, making him a less compatible potential recipient. It may also be associated with chronic renal failure. If used, as recommended, all currently available devices do not produce excessive hemolysis.
Many patients are in some degree of cardiogenic shock preoperatively. This may persist postoperatively if the assist device fails to produce the desired increase in cardiac output. Renal failure, associated with azotemia and abnormal free water clearance, is associated with a high mortality. Managing renal failure with hemodialysis, ultra-filtration, peritoneal dialysis or a combination of these techniques usually does not have a significant impact on improving outcome. Pulmonary failure is usually manifested by hypoxemia, increased intrapulmonary shunt and decreased compliance. Jaundice and elevations in the liver enzymes are the most common evidence of liver failure, although an elevated bilirubin may represent blood transfusion related hemolysis. Gastro-intestinal failure can be manifested by bleeding from the GI tract and/or prolonged ileus. The outcome of patients with multi-organ failure is directly related with the number of organs involved; the more organs involved in failure, the higher the mortality.
The future of artificial devices
Mechanical circulatory support has evolved over the last 40 years since DeBakey implanted the first VAD for post-cardiotomy support.  Applications for VADs are expanding and advances in technology continue to improve the design, ease of implantation, durability and complication rates in these devices. With smaller systems and power packs, mobility of the patient and long-term survival on artificial support is now a reality. Another generation of LVADs that allow the patient freedom of mobility and discharge at home are undergoing clinical trials and on their way to the market. These mostly contain small pumps implanted in the upper abdomen and controllers/battery packs carried or worn outside the body. The DuraHeart System (Terumo Heart, Inc., Ann Arbor, MI), Levacor VAD (World Heart, Oakland, CA) and VentrAssist VA4 (Ventracor Inc, Foster City, CA) are just a few examples of pumps that can be expected to continue advancement in this field of heart failure treatment.
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Department of Anesthesiology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, Arizona 85054
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3]
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