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Cardiac transplantation and mechanical circulatory support 

Cardiac transplantation and mechanical circulatory support

Chapter:
Cardiac transplantation and mechanical circulatory support
Author(s):

Jayan Parameshwar

and Steven Tsui

DOI:
10.1093/med/9780199204854.003.160502_update_002

Update:

Indications and use of ventricular assist devices.

Updated on 29 Oct 2015. The previous version of this content can be found here.
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date: 30 March 2017

Cardiac transplantation

Cardiac transplantation is the treatment of choice for selected patients with advanced heart failure: median survival exceeds 10 years and recipients enjoy an excellent quality of life, but availability is severely limited by shortage of donor organs. The need for lifelong immunosuppression is associated with side effects, including an increased incidence of malignancy. Newer immunosuppressive agents offer promise in reducing nephrotoxicity of conventional regimens and in delaying the onset of (currently inevitable) cardiac allograft vasculopathy.

Mechanical circulatory support

Ventricular assist devices (VADs) are mechanical blood pumps that work in parallel or series with the native ventricles. First-generation volume-displacement pulsatile VADs have largely been superseded by rotary blood pumps that generate continuous flow. Significant complications include bleeding, thromboembolism, and infection.

Temporary support—several devices are available for use in patients who require support for days to  weeks in the intensive care unit: these are invaluable in postcardiotomy cardiogenic shock and in patients who present in extremis with uncertain viability.

Chronic support—implantation of a durable VAD in patients with chronic heart failure can either be as a bridge to heart transplantation or as permanent support, sometimes referred to as destination therapy (DT). The REMATCH study (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure) randomized patients with endstage heart failure to best medical therapy or the implantation of the first-generation HeartMate I VAD: survival was improved in the device group (52% vs 25% at 1 year; 23% vs 8% at 2 years). A subsequent study randomizing similar heart failure patients between a newer continuous-flow left ventricular assist device (LVAD) (the HeartMate II) and the pulsatile HeartMate XVE showed that survival with continuous-flow VAD was even better (58% vs 24% at 2 years).

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