Mechanical support of the circulation followed by cardiac transplantation

Improvements in both mechanical circulatory support devices and immune therapy promise a wider use of sequential mechanical support as a bridge to orthotopic cardiac transplantation. The intra-aortic balloon pump, the left and right ventricular assist pumps, and the pneumatic artificial heart represent the range of devices capable of keeping a patient alive who is awaiting a donor organ. The major difficulty in using circulatory support devices is infection, which is caused by their required percutaneous tubes. We report here our experiences with mechanical circulatory support devices as a bridge to cardiac transplantation. In a series of 31 consecutive transplant procedures, six patients have required preoperative mechanical circulatory support. The intra-aortic balloon pump was used in two patients for 2 and 14 days, respectively, before transplantation. Both patients are well 10 and 11 months after the transplant procedure. Two patients required the left ventricular assist device for 11 and 21 days and are alive 3 weeks and 8 months, respectively, after transplantation. One patient was supported by the pneumatic artificial heart for 10 days before a donor heart became available but died of septic shock 17 days after transplantation. A second patient received a pneumatic artificial heart 7 days after transplantation when the heart transplant failed. He has been in stable condition for 45 days but is recovering from renal failure. Our early experiences indicate that either partial or total mechanical support as a bridge to transplantation is successful if overwhelming sepsis or renal failure can be avoided.