67 - Ventricular assist devices and cardiac transplantation

Summary

The first example of mechanical circulatory support is credited to Stuckey and colleagues who used an early heart–lung machine to support a patient suffering an acute myocardial infarction in 1957. In 1965, Spencer reported the use of a centrifugal pump in a patient with circulatory collapse after cardiac surgery. The management of cardiogenic shock and the ability to transiently support the heart was revolutionized by Kantrowitz and associates in 1968 with the clinical use of the intra-aortic balloon pump (IABP). Although the first ventricular assist devices (VAD) were pioneered in the 1970s, it wasn't until the late 1980s that the Thoratec, Novacor, and HeartMate assist devices attained widespread use as bridges to cardiac transplantation. In 1967, the treatment for end-stage heart disease was forever altered with the advent of heart transplantation. Currently in the USA, there are approximately 500 VADS placed each year and 2500 heart transplants performed in adults.

There are two goals associated with mechanical circulatory support. As with the IABP, the initial goal of the VAD is to stem the multiorgan dysfunction that ensues with poor perfusion secondary to cardiogenic shock; however, the long term goal of VAD therapy is to rehabilitate patients while awaiting cardiac transplantation. In some cases, VAD therapy has become the definitive treatment for a patient's end-stage heart disease. Mechanical support is both initiated and continued in the setting of optimized medical and pharmacological management of the failing heart patient.