Mechanical Circulatory Support in Heart Failure

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Abstract

Mechanical circulatory support devices have been in development since the late 1950s and are now challenging cardiac transplantation as the primary intervention for end-stage congestive heart failure. A diverse selection of devices is currently available, ranging from the size of a pencil to the size of two fists and with a spectrum of pumping characteristics, flows, positions in the chest, risks, and complications. The two basic types of device are pulsatile ‘volume displacement’ pneumatic pumps and non-pulsatile ‘rotary’ electric pumps. Over 15,000 patients have undergone device implantation. The majority of patients are discharged and results are accumulating that will allow us to determine when in the progression of heart failure we should add mechanical circulatory support devices to patient therapy. Selection criteria are evolving from risk factor analyses conducted over the past decade. A national registry will help to both organize patient and device selection and catalogue complications and long-term results.

Disclosure
The author has no conflicts of interest to declare.
Correspondence
Jack Copeland, MD, 200 W Arbor Dr, MC 8892, San Diego CA92103. E: jgcopeland@ucsd.edu
Received date
25 October 2010
Accepted date
18 January 2011

Pages

Mechanical circulatory support (MCS) devices are changing heart failure therapy. A spectrum of devices have become essential to the management of a variety of heart failure scenarios and, in the next few decades, this spectrum will expand and improve thousands of lives each year. The field has grown slowly and at considerable cost over the past 50 years but is now moving rapidly. Devices as small as a pencil and up to the size of two fists are being implanted in record numbers, with a total of over 15,000 implants worldwide. Many devices have been retired, some replaced by smaller, more efficient pumps and some eliminated by costly regulatory requirements and market forces. Several new devices are undergoing animal and early human trials but the field has been reduced to:

  • one left ventricular assist device (LVAD), approved for long-term use;
  • several LVADs approved for short-term use as a bridge to transplantation or recovery;
  • one total artificial heart (TAH), approved for use as a bridge to transplantation; and
  • several temporary rescue pumps, which could be used to support either ventricle or as an extracorporeal membrane oxygenation (ECMO) system to support the heart and lungs.

This technology brings surgeons, cardiologists, engineers, nurses, and administrators together in a powerful consortium that challenges industry and government to make devices more affordable and more readily available. Undoubtedly, there will be a greater use of these devices in short-term crises, in the long-term treatment of chronic heart failure, for use as a bridge to transplantation and for the recovery of native hearts. Outpatient care of people using MCS devices enables communication between referring physicians and local communities but creates a need for the dissemination of general knowledge on the devices and the care and management of patients using these devices.
Cost is a major consideration. Most long-term devices cost about US$75,000 per artificial ventricle. Temporary devices are cheaper, ranging from about US$10,000 for the simplest to US$25,000 per ventricle for the more complex. At US$2,000–5,000 per day for acute hospital care, length of hospital stay rapidly becomes the limiting factor. Reduction in the cost of MCS has been envisioned as an intermediate goal of the pioneers in the field. It was hoped that the general acceptance of MCS devices—and their more widespread use, which could in turn improve manufacturing efficiency—would reduce cost.

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References
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