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The HeartMate left ventricular assist system (LVAS) is being used with increasing frequency as a bridge to heart transplantation and for long-term support of chronic heart failure patients who are not transplant candidates. The surgical techniques and anatomic placement of the HeartMate are factors in minimizing complications that occur during long-term use. Device related bleeding, infection, and other intraabdominal complications are serious adverse events associated with the position of the LVAS. Clinical data from 48 HeartMate supported patients were analyzed retrospectively to determine differences in serious complication rates between intraperitoneal (IP) and extraperitoneal (EP) LVAS placement. The LVAS was placed IP in 37 patients (77%) and EP in 11 patients (23%). The occurrence of postoperative bleeding that required reoperation was 57% in the IP group and 64% in the EP group. Device related bleeding was 8% in the IP group and 29% in the EP. Neither difference in bleeding rate was statistically significant. The overall infection rate during the entire period of LVAS support was similar between groups (IP, 45.7%; EP, 46.2%; p = 0.25); however, device related infection occurred more often in the EP group (46%; IP, 14%; p = 0.025). All patients who recovered from LVAS implantation experienced mild early satiety, but were otherwise free of intra-abdominal complications. The transplantation rate was 64% for the IP group and 78% for the EP group. IP LVAS placement may offer additional protection against device related infections.

Background: This study assessed the effect of prolonged left ventricular unloading on native ventricular function., Methods: We reviewed data from 31 patients (30 men, 1 woman) supported more than 30 days (mean, 137 days; range, 31 to 505 days) with the HeartMate left ventricular assist system. The patients' mean age was 46 years (range, 22 to 64 years); 17 had idiopathic and 14 had ischemic cardiomyopathy. Data (anatomic, physiologic, hemodynamic, histologic, and biochemical) were collected at the time of HeartMate implantation, during support with the device temporarily off, and at the time of device explantation., Results: Routine chest roentgenogram showed improvement in cardiothoracic ratio (0.62 +/- 0.04 to 0.55 +/- 0.03; p < 0.0001). Echocardiography performed with the pump off showed a significant decrease in left ventricular end-diastolic dimension (6.81 +/- 0.87 cm to 5.39 +/- 1.08 cm; p < 0.0005) and a significant improvement in ejection fraction (0.11 +/- 0.05 to 0.22 +/- 0.17; p < 0.02). Cardiac index increased (1.96 +/- 0.52 L.min-1.m-2 to 2.93 +/- 0.73 L.min-1.m-2; p < 0.0001), mean aortic pressure increased (71.40 +/- 10.63 mm Hg to 76.33 +/- 16.84 mm Hg; p = 0.48), pulmonary capillary wedge pressure decreased (24.18 +/- 6.27 mm Hg to 14.48 +/- 3.01 mm Hg; p < 0.0001), and pulmonary vascular resistance decreased (3.34 +/- 2.00 Wood units to 2.51 +/- 0.88 Wood units; p < 0.05). Comparisons of tissue samples taken at the time of implantation and at the time of transplantation showed a marked reduction in myocytolysis. Calcium uptake, calcium-binding rates, and lipid levels normalized in patients studied. Plasma norepinephrine levels decreased to near normal levels., Conclusion: Prospective studies are now indicated to determine whether device removal without transplantation may be beneficial in selected patients.

Infection is a problem in patients undergoing support with left ventricular assist systems. To better understand the nature of this problem, we retrospectively analyzed data on 56 patients supported by the HeartMate (Thermo Cardiosystems, Inc, Woburn, MA) left ventricular assist system. Infection was defined as fever > 38 degrees C, white blood count > 12,000 cells/ml, and a need for antimicrobial therapy. Of the 56 patients, 25 (41%) had an infection. Device related infections (as determined by positive culture from driveline, housing, or inflow or outflow tract) occurred in eight patients (14.3%). The most common sites of infection were the respiratory system (42.4%), the central venous catheter (27.8%), and blood (18.3%). Of the positive cultures, 84% were bacterial and 16% fungal. There were no positive viral cultures. Positive cultures from left ventricular assist system related sites made up only 8.7% of the total. All but one of the patients with device related infections survived to transplantation. The long-term survival rate for patients in this group after transplantation was 77.8%. Two patients required surgical revision of the driveline because of infection. Both were free of infection postoperatively. Patients who stayed in the intensive care unit for longer periods had a greater risk of infection (uninfected, 35 days; infected, 78 days). In conclusion, although infection is a problem in patients undergoing support with left ventricular assist systems, it does not preclude survival to transplantation or alter the survival rate after transplantation.