Downloaded from http://heart.bmj.com/ on September 16, 2016 - Published by group.bmj.

com
Heart Online First, published on May 6, 2015 as 10.1136/heartjnl-2014-306789
Review

Ventricular assist devices for treatment of acute

heart failure and chronic heart failure
James N Kirkpatrick,1 Georg Wieselthaler,2 Martin Strueber,3
Martin G St John Sutton,1 J Eduardo Rame1
1
Hospital of the University of ABSTRACT significant improvements in quality of life and func-
Pennsylvania, Philadelphia, Despite therapeutic advances that improve longevity and tional capacity after LVAD implantation to a degree
Pennsylvania, USA
2
University of California at quality of life, heart failure (HF) remains a relentless that is unrivalled with any other non-surgical HF
San Francisco Medical Center, disease. At the end stage of HF, patients may become therapy in refractory, advance New York Heart
San Francisco, California, USA eligible for mechanical circulatory support (MCS) for the Association (NYHA) class IV patient populations.3
3
Spectrum Health, Grand indications of stabilising acute cardiogenic shock or for But there are patients who derive limited benefit,
Rapids, Michigan, USA
chronic HF management. MCS use is growing rapidly in related to preimplant comorbidities that are inde-
Correspondence to the USA and some countries of the European Union, pendent of but may interact with post-LVAD com-
Dr James N. Kirkpatrick, especially in transplant-ineligible patients. In others, it plications (such as RV failure, bleeding, pump
Hospital of the University of remains largely a tool to stabilise patients until heart thrombosis, stroke and infection). Even for optimal
Pennsylvania, 3400 Spruce St., transplant. MCS comprises a heterogeneous group of candidates, this spectrum of potential complications
HUP 9001 Gates, Philadelphia,
PA 19104, USA; james. temporary and durable devices which augment or requires constant vigilance and management by a
kirkpatrick@uphs.upenn.edu replace the pumping function of one or both ventricles, coordinated care team. These complications and
with postimplant 2 year survival rivalling that of other complexities have led to recent recognition
Received 13 February 2015 transplant in selected, lower-risk patients. In transplant- of the importance of palliative care expertise in
Revised 3 April 2015
eligible and non-transplant-eligible patients, caring for LVAD patients.4
Accepted 6 April 2015
improvement in end-organ perfusion, functional capacity
and quality of life have been noted. Even for optimal INDICATIONS
candidates, however, there are a host of potential Patients without prior cardiac dysfunction who
complications that require constant vigilance of a require haemodynamic support during an acute
coordinated care team. Recently, there has been official insult undergo MCS as ‘rescue therapy’. The
recognition of the importance of palliative care expertise current approach in many centres is to stabilise the
in advance care planning preimplant and management circulation with temporary circulatory support
of patients with ventricular assist devices at the end of (TCS)5 strategies such as extracorporeal membrane
their lives. oxygenation (ECMO) while attempting to recover
heart function with revascularisation or tailored
medical therapy. Patients who cannot be weaned
Heart Failure (HF) is acute and chronic, presenting from TCS/ECMO but who have recovered end-
with haemodynamic decompensation and life- organ function are considered for durable, predom-
threatening arrhythmias, and smouldering symp- inantly left-sided ventricular assist device support.
toms such as dyspnoea and fatigue. HF afflicts over In the USA, the ‘bridge to transplant’ indication for
20 million persons worldwide. Over the last MCS stabilises the circulation in the setting of very
25 years the prevalence has doubled and will poor cardiac function, usually with improved end-
double again between 2030 and 2040. Refractory organ perfusion and capacity. Patients who are not
symptoms afflict at least 5% of HF sufferers. After transplant candidates receive MCS as ‘destination
failing medical and cardiac resynchronisation ther- therapy’ (DT) and have constituted the largest per-
apies, patients with end-stage HF are considered centage of patients with LVADs since 2011.1 In
for ‘advanced therapies’, including palliative ino- Europe, where the scarcity of organs is much more
tropes, heart transplant and, increasingly, mechan- pronounced in many countries, there is no current
ical circulatory support (MCS). discrimination between DT and bridge to transplant,
MCS comprises a heterogeneous group of and VADs are implanted without an antecedent
devices which augment or replace the pumping evaluation for heart transplantation in cases of
function of one or both ventricles, including tem- advanced, refractory HF. In the European experi-
porary cardiac support (TCS) and durable assist ence, the transplant rate after VAD placement is very
devices. The use of durable LV assist devices low. Since cardiac transplantation is a more realistic
(LVADs) in chronic HF has increased dramatically, option after VAD therapy in the USA, MCS is used
with up to 2511 implants in 2013 in the USA.1 For in cases in which transplant candidacy is unclear, as
many patients awaiting transplant2 and for many a ‘bridge to candidacy’ under the indication of DT.
others in the USA and Europe who are not This option allows time to investigate appropriate-
transplant-eligible, LVADs stabilise deteriorating ness of transplant while stabilising and often
To cite: Kirkpatrick JN, haemodynamic and metabolic status and provide a
Wieselthaler G, Strueber M,
improving critical parameters such as increased pul-
et al. Heart Published Online
long-term bridge for heart transplantation. The monary vascular resistance, a marker of risk due to
First: [ please include Day 2 year survival for a cohort of continuous flow early right HF after heart transplantation.6
Month Year] doi:10.1136/ LVAD patients with low-risk variables rivals that of Myocardial unloading with mechanical assist device
heartjnl-2014-306789 cardiac transplantation.1 Studies have identified support in conjunction with optimised HF therapies
Kirkpatrick JN, et al. Heart 2015;0:1–6. doi:10.1136/heartjnl-2014-306789 1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& BCS) under licence.
 Downloaded from http://heart.bmj.com/ on September 16, 2016 - Published by group.bmj.com

Review

induce myocardial recovery in a subgroup of patients with blood from the left ventricular outflow tract (LVOT) and acceler-
chronic non-ischaemic cardiomyopathy. If there is proof that ates it into the aortic root.
the degree of myocardial reverse remodelling is significant by Durable VADs with intracorporeal pumps provide long-term
examining myocardial function at minimum support, these support to ambulatory patients. Multiple LVADs have received the
‘bridge to recovery’ patients may be considered for LVAD European CE mark, but here we focus on the two with CE and
explant.7 A current non-randomised, multicentre study in the United States Food and Drug Administration (FDA) approval—
USA is trying to determine the success of this ‘bridge to recovery’ HeartMate II (Thoratec, Pleasanton, California, USA) and
strategy. HeartWare Ventricular Assist System (HVAS) (Heartware,
Framingham, Massachusetts, USA). Both systems consist of a con-
DEVICES tinuous flow pump, an inflow cannula, an outflow conduit, a drive
Early generation temporary VADs employ extracorporeal pumps line, a controller and batteries (figure 1). The HeartMate II
with surgically implanted large bore catheters. These pumps (HMII) pump is a propeller (‘axial flow’). The HVAS employs a
simulate cardiac systolic pulsation and include biological rotating disc (‘centrifugal flow’). Both draw blood from an inflow
valves positioned at the inflow and outflow ends of the pump. cannula in the LV apex and accelerate it through an outflow graft
Later generation devices are smaller and more portable. into the ascending aorta. The output changes with the speed of
Paracorporeal devices have pumps that are strapped to the body rotation of the propeller or the disc (rpm). Because the flow is con-
and connected via shorter catheters, allowing hospital discharge in tinuous, there is no need for valves, and the output depends on
some cases (eg, Paracorporeal Ventricular Assist Device (PVAD), preload in the LV and afterload in the ascending aorta, in addition
Thoratec, Pleasanton, California, USA). Extracorporeal VADs have to speed. Nonetheless, the output is usually pulsatile, reflecting
been supplanted in many institutions by ECMO and TCS devices residual ventricular contraction.
(eg, Centrimag, Thoratec, Pleasanton, California, USA) which The LVAD controller tracks power and flow, and alarms when
provide full support. Partial support TCS is used for patient stabil- these parameters fall out of the normal range. Power is directly
isation and during percutaneous coronary interventions and cath- measured in watts, whereas flow is calculated based on speed
eter ablations.5 The TandemHeart (Cardiac Assist Pittsburgh, and power. High power and low flow alarms signal one of many
Pennsylvania, USA) has an extracorporeal pump that draws blood complications. Echocardiography is usually required to deter-
from a catheter placed through the venous system, across the mine the cause (figures 2 and 3).
interatrial septum and into the left atrium. The outflow graft deli- Patients with biventricular failure or those with significant
vers blood through a femoral artery catheter. The Impella intraventricular thrombi may be candidates for a total artificial
(Abiomed Danvers, Massachusetts, USA) consists of a rotor pump heart (TAH), as a bridge to transplantation, or for biventricular
located within a large bore catheter placed through the arterial assist device placement with two continuous flow pumps.8 The
system, retrograde across the aortic valve. The inlet portion draws long-term durability of TAH and biventricular assist devices has

Figure 1 X-rays demonstrating

location and photos of pump
components for the two LV assist
device systems that have received CE
Mark and FDA approval. Heartmate II
axial flow device (Thoratec,
Pleasanton, California, USA) (left) and
HVAD centrifugal flow device
(Heartware, Framingham,
Massachusetts, USA) (right). Both
systems consist of a pump placed into
a ‘pump pocket’ below the diaphragm
(Heartmate II) or within the chest
cavity (HVAD). Both pumps are
connected to the LV apex via a short
inflow cannula (red arrow) and to the
ascending aorta via an outflow conduit
anastomosed end to side (blue arrow).
The outflow conduits are radiopaque
and drawn in the figure for reference.
The yellow arrows indicate the system
controllers for both devices.

2 Kirkpatrick JN, et al. Heart 2015;0:1–6. doi:10.1136/heartjnl-2014-306789

 Downloaded from http://heart.bmj.com/ on September 16, 2016 - Published by group.bmj.com

Review

Figure 2 Diagnosis of LV assist

device (LVAD) complications—high
flow. Several diagnoses lead to high
flow alarms. Echocardiography is
necessary to demonstrate the
complication causing the alarm. A high
flow alarm with no change in LV size
and reduced AV opening is concerning
for sepsis. A high flow alarm in the
setting of LV enlargement, however,
can signal pump thrombosis or
significant worsening of aortic
regurgitation. No change in LV size or
aortic valve opening with increased
LVAD speed (‘ramp study’), along with
laboratory findings such as elevated
lactate dehydrogenase, is highly
suggestive of pump thrombosis.
Elevations in flow can also accompany
ventricular recovery, with increased
ejection through the LVAD, and is
identified by increased LVEF on
echocardiography.

not yet been established. Since the transplant rate in Europe is INTERMACS 1 currently comprise 15% of US LVAD implants,
very low, biventricular support is rarely used, and the use of the down from 30% before 2010, in part because many such patients
TAH is restricted to a few centres. do poorly regardless of LVAD.9 INTERMACS 2–3 stages now
account for 66% of LVAD implants.1 Patients who are stable
PATIENT CANDIDACY without inotropic support but are still at an advanced stage
Box 1 details cautions and contraindications concerning durable (INTERMACS 4–6)10 are more controversial. Some centres
LVADs. Preimplant echocardiography is essential to detect struc- implant patients who are not inotrope-dependent but meet
tural pathologies requiring correction at the time of implant. criteria on the basis of cardiopulmonary reserve (exercise cardio-
Candidates for MCS are classified into INTERMACS profiles pulmonary testing with measurement of peak oxygen consump-
(table 1). Most VAD implants are performed for patients in tion). The debate over implanting less sick patients reflects the
INTERMACS 1–3 (worst cardiac decompensation). Patients in desire to apply LVAD therapy before it is ‘too late’ (a patient has

Figure 3 Diagnosis of LV assist

device (LVAD) complications—low
flow: Multiple pathological states
cause low flow alarms. LV enlargement
with rightward interventricular septal
shift and increased mitral regurgitation
suggests either increases in systemic
vascular resistance or kinking/
obstruction of the outflow conduit.
Echocardiographic assessment of aortic
valve opening and cannula velocities
can help differentiate between these
two diagnoses. A contrast-enhanced
CT scan can identify kinking of the
conduit (figure 4). A small LV with
leftward septal shift accompanies LV
underfilling, whether from tamponade
or RV dysfunction. Echocardiography
identifies chamber compression from a
pericardial effusion or thrombus, or RV
enlargement with reduced function
and increased tricuspid regurgitation.
LV underfilling from dehydration,
overdiuresis or bleeding can manifest
as a suction event, identified on
echocardiography as a portion of the
septum, a chord or a trabecula drawn
into, and partially obstructing, the
orifice of the LVAD inflow (figure 5).

Kirkpatrick JN, et al. Heart 2015;0:1–6. doi:10.1136/heartjnl-2014-306789 3

 Downloaded from http://heart.bmj.com/ on September 16, 2016 - Published by group.bmj.com

Review

Table 2 LVAD outcomes and complications (INTERMACS 2014 Q3

Box 1 Contraindications and cautions for LV assist
Report)1
device implant
12 months <3 months >3 months

Clinical Overall survival (%) 79

Active systemic infection LVAD, no RVAD
Clotting or bleeding diathesis Alive with device 61.9
Irreversible hepatic disease Transplanted 19.8
Malnutrition Explanted (recovery) 0.7
Significant cognitive dysfunction Dead 17.6
Severe psychiatric disease LVAD with RVAD
Addiction Alive with device 43.2
Echocardiographic Transplanted 16
>Mild aortic regurgitation Explanted (recovery) 0
>Moderate tricuspid regurgitation Dead (%) 40.8
Ventricular septal defect TAH
Atrial septal defect/patent foramen ovale Alive with device 11
Severe RV dysfunction Transplanted 60.5
Aortopathy* Explanted (recovery) 0
Dead 28.4
*Aneurysm, severe plaque in ascending aorta complicates Other events (n/100 pt months)
placement of outflow conduit. Rehospitalisation 21 16.12
Bleeding 19.06 3.36
Arrhythmia 11.33 1.04
Infection 15.56 3.96
irreversible end-organ dysfunction) but not ‘too soon’ (and
Driveline 1.29 1.45
thereby unnecessarily expose patients to the attendant risks).
Exit cannula 0.04 0.03
Psychosocial factors play an important role in assessing candi-
Pump interior 0.05 0.02
dacy for VADs. Implanted devices require constant vigilance to
Pump pocket 0.34 0.16
recognise and manage complications (see below). Patients
Other serious event 13.36 1.93
without adequate support structures and those whose vigilance
Device malfunction 2.72 1.56
may be impaired by psychiatric disease, cognitive dysfunction or
Neurological dysfunction 4.01 1.23
drug or alcohol addiction may be poor candidates.4 11
Renal dysfunction 3.86 0.48
Respiratory failure 7.55 0.49
VAD COMPLICATIONS Hepatic dysfunction 1.44 0.22
VAD complication rates and timing vary between studies, but Venous thromboembolism 1.76 0.07
the INTERMACS registry from the USA documents the most LVAD, LV assist device; TAH, total artificial heart; RVAD, Right Ventricular Assist
Device.
frequent occurrences within the first 3 months after implant
(table 2).
Driveline exit site infections portend a poor prognosis.12
Meticulous care of the driveline exit site is crucial, and early but recent studies suggest a higher event rate since 2011.13 14
treatment of infection with systemic antibiotics, debridement High power and low flow with laboratory markers of haemoly-
and driveline reposition may be necessary. Driveline infections sis usually accompany pump thrombosis that obstructs the
occur in 10–20% and can seed the pump, necessitating pump impeller or disc. Diagnosis is aided by a ‘ramp study’ with an
exchange or transplant in most cases. echocardiogram that measures the response of the LV size and
Pump thrombosis potentially causes pump failure and/or other parameters to increasing speeds.15 16 While more aggres-
embolic stroke. The traditional prevalence is 7–8% of implants, sive anticoagulation and thrombolytics have been used success-
fully, bleeding is a significant risk, and a pump exchange is
often required in cases of refractory or recurrent pump
thrombosis.
Table 1 INTERMACS classification system
Anticoagulation, necessary to prevent thrombus formation in
Class Description Notes the pump or the aortic root, is complicated by GI bleeds.
Patients with continuous flow devices have reduced levels of
1 Critical cardiogenic shock Includes patients with temporary
mechanical support devices
high molecular weight von Willebrand factor monomers.17–19 In
2 Progressive decline despite Includes patients with temporary
addition, decreased pulse pressure from continuous flow may
inotropic support mechanical support devices contribute to the development of arteriovenous malformations
3 Inotrope dependent but stable in the gastrointestinal (GI) tract.20 Intracerebral haemorrhage is
4 Resting symptoms, not on another important complication which may increase with
inotropes bacteraemia.21
5 Symptoms prevent exertion Hypovolemia, from bleeding, dehydration or sepsis, can lead
6 Symptoms limit exertion to underfilling of the LV and a ‘suction’ event, in which LV
7 Marked exertional symptoms walls, trabeculae or mitral chordal apparatus are drawn into and
obstruct the inflow cannula. Suction events can result in
4 Kirkpatrick JN, et al. Heart 2015;0:1–6. doi:10.1136/heartjnl-2014-306789
 Downloaded from http://heart.bmj.com/ on September 16, 2016 - Published by group.bmj.com

Review

Figure 4 Suction event induced

during ramp study. The left panel
demonstrates a parasternal long-axis
view of a Heartmate II device set at
9200 rpm. The right panel shows a
significant reduction in LV size (blue
arrow) after increase in the rpm to
11 600 rpm. The posteromedial
papillary muscles obstruct the orifice of
the LV assist device inflow cannula
(green arrow).

syncope and ventricular arrhythmias. LV underfilling can also Overfilling of the LV occurs not only in the setting of pump
result from pericardial tamponade and RV failure in the postim- dysfunction but also with elevated systemic vascular resistance,
plant setting (figures 2–4). cannula obstruction (inflow cannula thrombosis and outflow
Early RV failure is defined as need for mechanical support of cannula kinking), aortic regurgitation, and worsening LV systolic
the RV or >14 days of inotropic support. Although LVAD func- and diastolic functions (figure 5). Patients may experience pul-
tion decongests the LV, reducing back pressure on the pulmonary monary congestion, fatigue and light-headedness.
circuit and the RV, it also delivers a greater preload to the RV. In
addition, interventricular septal shift into the LV may tether the PALLIATIVE CARE
tricuspid septal leaflet, leading to significant tricuspid regurgita- The morbidity and mortality of LVAD complications highlight
tion and further RV volume overload. Demands on the RV to the importance of palliative care. Advance care planning is
match LVAD-augmented left-sided cardiac output, combined recommended for LVAD patients,9 10 and the Centers for
with potentially reduced RV perfusion pressure due to high RV Medicare and Medicaid Services require that DT LVAD manage-
systolic and diastolic pressures leads to supply-demand perfusion ment teams include a palliative care specialist.26 Palliative care is
mismatch and ischaemia. Worsening RV dilatation and falling not synonymous with hospice but rather functions alongside
RV stroke volume further displace the septum and underfill the invasive and curative treatments. Palliative care specialists assist
LV, potentially leading to suction events, as well as loss of septal patients with defining values and goals that inform decision-
contribution to RV contraction. Multiple studies have demon- making. Swetz et al27 recommend guiding patients through a
strated correlations between a wide variety of preoperative ‘preparedness plan’ to elicit patient wishes in light of potential
laboratory, haemodynamic and echocardiographic variables, and VAD outcomes that include device failure, intolerable quality of
postimplant RV failure.22–25 Long-term RV failure is less well life, catastrophic complications (eg, debilitating stroke) and
characterised but may reflect failure of RV-PA coupling: despite development of comorbid conditions (eg, metastatic cancer). Of
decreased left-sided congestion induced by the LVAD, the RV note, the most frequent primary causes of death reported in
function fails to improve. patients with LVADs are neurological dysfunction (18%),

Figure 5 Outflow conduit kink.

Contrast enhanced 2D modified axial
view (left) and 3D reconstruction
(right) demonstrate kink in the outflow
conduit (blue arrows).

Kirkpatrick JN, et al. Heart 2015;0:1–6. doi:10.1136/heartjnl-2014-306789 5

 Downloaded from http://heart.bmj.com/ on September 16, 2016 - Published by group.bmj.com

Review

multisystem organ failure (15%), withdrawal of LVAD support 6 Kutty RS, Parameshwar J, Lewis C, et al. Use of centrifugal left ventricular assist
(9.6%) and major infection (9.5%).1 Palliative care consultation device as a bridge to candidacy in severe heart failure with secondary pulmonary
hypertension. Eur J Cardiothorac Surg 2013;43:1237–42.
can guide symptom relief, particularly important in older 7 Birks EJ, George RS, Hedger M, et al. Reversal of severe heart failure with a
patients with multiple symptomatic comorbidities. At the end of continuous-flow left ventricular assist device and pharmacological therapy:
patients’ lives, palliative care facilitates decision-making about a prospective study. Circulation 2011;123:381–90.
life-sustaining interventions and potential transition to hospice. 8 Copeland JG, Smith RG, Arabia FA, et al, CardioWest Total Artificial Heart
Investigators. Cardiac replacement with a total artificial heart as a bridge to
A growing number of hospices are willing to provide services to
transplantation. N Engl J Med 2004;351:859–67.
patients with active LVADs, in conjunction with an MCS team. 9 Boye AJ, Ascheim DD, Russo MJ, et al. Clinical outcomes for continuous flow left
ventricular assist device patients stratified by pre-operative INTERMACS
CONCLUSIONS classification. J Heart Lung Transplant 2011;30:402–7.
MCS, especially in transplant ineligible (DT) patients, is poised 10 Yancy CW, Jessup M, Bozkurt B, et al, American College of Cardiology Foundation;
American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA
to continue its rapid expansion in treating acute and chronic guideline for the management of heart failure: a report of the American College of
HF. Significant strides have been taken in the current era of con- Cardiology Foundation/American Heart Association Task Force on Practice
tinuous flow device support, including increased 1 year and Guidelines. J Am Coll Cardiol 2013;62:e147–239.
2 years survival and improved quality of life and functional cap- 11 Peura JL, Colvin-Adams M, Francis GS, et al, American Heart Association Heart
Failure and Transplantation Committee of the Council on Clinical Cardiology;
acity in a majority of patients. This progress, in conjunction
Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council
with the noted complications, has fuelled a spirit of investiga- on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; Council
tion to engineer and operate the pumps with the least adverse on Cardiovascular Radiology and Intervention, and Council on Cardiovascular
events and the most durability. Smaller MCS devices for tem- Surgery and Anesthesia. Recommendations for the use of mechanical circulatory
porary and long-term support hold promise for reduced implant support: device strategies and patient selection: a scientific statement from the
American Heart Association. Circulation 2012;126:2648–67.
morbidity and mortality (especially in smaller adults and chil- 12 Gordon RJ, Weinberg AD, Pagani FD, et al, Ventricular Assist Device Infection Study
dren) as well as promoting pulsatile flow patterns which may Group. Prospective, multicenter study of ventricular assist device infections.
reduce some LVAD complications (bleeding and thrombosis). Circulation 2013;127:691–702.
Furthermore, future devices with improved biocompatibility will 13 Rame JE, Atluri P, Acker MA. Unexpected abrupt increase in left ventricular assist
device thrombosis. N Engl J Med 2014;370:1466–7.
reduce haemolysis by containing the spectrum of shear stress on
14 Starling RC, Moazami N, Silvestry SC, et al. Unexpected abrupt increase in left
blood components and may impact the rate of pump throm- ventricular assist device thrombosis. N Engl J Med 2014;370:33–40.
bosis. Nonetheless, more research is needed to identify appro- 15 Estep JD, Vivo RP, Cordero-Reyes AM, et al. A simplified echocardiographic
priate MCS candidates in terms of comorbidities and technique for detecting continuous-flow left ventricular assist device
psychosocial conditions, as well as determine the optimal time malfunction due to pump thrombosis. J Heart Lung Transplant
2014;33:575–86.
in the HF disease course to consider implantation. 16 Uriel N, Morrison KA, Garan AR, et al. Development of a novel echocardiography
ramp test for speed optimization and diagnosis of device thrombosis in
Acknowledgements The authors thank Ted Plappert, CVT, who edited the continuous-flow left ventricular assist devices: the Columbia ramp study. J Am Coll
figures, and Christyna Justice, RN, BSN, VAD coordinator, who provided VAD Cardiol 2012;60:1764–75.
component photos for figure 1. 17 Uriel N, Pak SW, Jorde UP, et al. Acquired von Willebrand syndrome after
Contributors JNK responded to the call for the manuscript/conceived of the continuous-flow mechanical device support contributes to a high prevalence of
format. JNK, GW, MS, MGSJS and JER all participated in drafting the manuscript bleeding during long-term support and at the time of transplantation. J Am Coll
and revising for important content. All approve of the manuscript. Cardiol 2010;56:1207–13.
18 Malehsa D, Meyer AL, Bara C, et al. Acquired von Willebrand syndrome after
Competing interests JNK is a subinvestigator for a pending Cardiac Surgical Trials
exchange of the HeartMate XVE to the HeartMate II ventricular assist device. Eur J
Network (NHLBI, NINDS, NIH) study on myocardial regeneration in patients with
Cardiothorac Surg 2009;35:1091–3.
LVADs. GW is a proctor for Heartware and an investigator for Heartmate II and
19 Wever-Pinzon O, Selzman CH, Drakos SG, et al. Pulsatility and the risk of
Heartware trials. MS is an investigator for Heartmate II and Heartware trials. JER
nonsurgical bleeding in patients supported with the continuous-flow left ventricular
reports the following research related disclosures: Principle Investigator for Heartmate
assist device HeartMate II. Circ Heart Fail 2013;6:517–26.
II (Thoratec), Heartware (Heartware) and C-Pulse (Sunshine Heart, Eden Prairie, MN)
20 Demirozu ZT, Radovancevic R, Hochman LF, et al. Arteriovenous malformation and
trials. He is also a member of the protocol writing committee for the REVIVE-IT
gastrointestinal bleeding in patients with the HeartMate II left ventricular assist
study (NHLBI and Thoratec).
device. J Heart Lung Transplant 2011;30:849–53.
Provenance and peer review Commissioned; externally peer reviewed. 21 Aggarwal A, Gupta A, Kumar S, et al. Are blood stream infections associated with
an increased risk of hemorrhagic stroke in patients with a left ventricular assist
REFERENCES device? ASAIO J 2012;58:509–13.
1 Kirklin JK, Naftel DC, Cantor RS, et al. INTERMACS 2014 Q3 report, The Data 22 Matthews JC, Koelling TM, Pagani FD, et al. The right ventricular failure risk score a
Collection and Analysis Center, University of Alabama at Birmingham, 22 December pre-operative tool for assessing the risk of right ventricular failure in left ventricular
2014. http://www.uab.edu/medicine/intermacs/images/Federal_Quarterly_Report/ assist device candidates. J Am Coll Cardiol 2008;51:2163–72.
Statistical_Summaries/Federal_Partners_Report_2014_Q3.pdf (accessed 2/3/15). 23 Kormos RL, Teuteberg JJ, Pagani FD, et al. Right ventricular failure in
2 Stehlik J, Stevenson LW, Edwards LB, et al. Organ allocation around the world: patients with the HeartMate II continuous-flow left ventricular assist device:
insights from the ISHLT International Registry for Heart and Lung Transplantation. incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg
J Heart Lung Transplant 2014;33:975–84. 2010;139:1316–24.
3 Rogers JG, Aaronson KD, Boyle AJ, et al. Continuous flow left ventricular assist 24 Vivo RP, Cordero-Reyes AM, Qamar U, et al. Increased right-to-left ventricle
device improves functional capacity and quality of life of advanced heart failure diameter ratio is a strong predictor of right ventricular failure after left ventricular
patients. J Am Coll Cardiol 2010;55:1826–34. assist device. J Heart Lung Transplant 2013;32:792–9.
4 Feldman D, Pamboukian SV, Teuteberg JJ, et al., International Society for Heart and 25 Raina A, Seetha Rammohan HR, Gertz ZM, et al. Postoperative right ventricular
Lung Transplantation. The 2013 International Society for Heart and Lung failure after left ventricular assist device placement is predicted by preoperative
Transplantation Guidelines for mechanical circulatory support: executive summary. echocardiographic structural, hemodynamic, and functional parameters. J Card Fail
J Heart Lung Transplant 2013;32:157–87. 2013;19:16–24.
5 Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert 26 Decision Memo for Ventricular Assist Devices for Bridge-to-Transplant and
Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Destination Therapy (CAG-00432R). Centers for Medicare and Medicaid Services.
Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?
Cardiological Society of India, and Sociedad Latino Americana de Cardiologia NCAId=268 (accessed 2/3/15).
Intervencion; Affirmation of Value by the Canadian Association of Interventional 27 Swetz KM, Freeman MR, AbouEzzeddine OF, et al. Palliative medicine consultation
Cardiology-Association Canadienne de Cardiologie d’intervention. J Am Coll Cardiol for preparedness planning in patients receiving left ventricular assist devices as
2015. destination therapy. Mayo Clin Proc 2011;86:493–500.

6 Kirkpatrick JN, et al. Heart 2015;0:1–6. doi:10.1136/heartjnl-2014-306789

 Downloaded from http://heart.bmj.com/ on September 16, 2016 - Published by group.bmj.com

Ventricular assist devices for treatment of

acute heart failure and chronic heart failure
James N Kirkpatrick, Georg Wieselthaler, Martin Strueber, Martin G St
John Sutton and J Eduardo Rame

Heart published online May 6, 2015

Updated information and services can be found at:

http://heart.bmj.com/content/early/2015/05/06/heartjnl-2014-306789

These include:

References This article cites 24 articles, 6 of which you can access for free at:
http://heart.bmj.com/content/early/2015/05/06/heartjnl-2014-306789
#BIBL
Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Topic Articles on similar topics can be found in the following collections

Collections Review articles (111)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/