Mechanical Circulatory Support Devices

Heart failure (HF) is a global public health concern that has the potential to reach epidemic proportions. The gold standard for treating end-stage HF remains heart transplantation. Unfortunately, given the scarcity of available organs, alternative means for providing cardiac support are required. Mechanical circulatory support devices (MCSDs) have the potential to treat many patients with end-stage HF. They replace some of the mechanical functions of the failing heart to improve cardiac output and organ perfusion. These include the intra-aortic balloon pump, extracorporeal membrane oxygenation, ventricular assist devices, and the total artificial heart. In this chapter, we will discuss a brief history of MCSD, available devices, indications, patient selection, surgical procedures, postoperative management, complications, and outcomes

Detecting Invasive Fungal Disease in Surgical Patients: Utility of the (1 3)- b-d-Glucan Assay

Background: The specificity and sensitivity of the (1 3)-b-d-glucan (BDG) assay in surgical patients needs further investigation. We hypothesized that the BDG assay would have lower sensitivity/specificity compared with that of medical patients. Methods: We reviewed patients who had undergone laparotomy, gastrectomy, hepatectomy, or colectomy and had a BDG assay post-operatively. Results: A total of 71 patients met study criteria. There were 29 (40.8%) who had proven/probable invasive fungal infection. Sensitivity for BDG level ‡80 diagnosed within one week of the assay draw was 77.3% (95% confidence interval [CI], 54.6–92.2%), and specificity was 44.9% (95% CI, 30.7–59.8). The positive predictive value was 38.6% (95% CI, 31.0–46.9%), and negative predictive value was 82.5% (95% CI, 65.7–91.0%). A BDG assay result of 149 pg/mL had a classification rate of 63.4%. Therefore, a BDG assay result ‡150 pg/mL has a sensitivity of 78.6% and a specificity of 41.4%. Conclusion: A BDG assay can be useful for ruling out invasive fungemia in post-operative patients

Continuous flow left ventricular assist device technology has influenced wait times and affected donor allocation in cardiac transplantation

ObjectiveBridge to transplantation patients with continuous flow left ventricular assist devices (cfLVADs) are assigned United Network for Organ Sharing status 1A or 1B priority while awaiting orthotopic heart transplantation. We investigated the influence of cfLVAD on the waitlist times and organ allocation.MethodsThe United Network for Organ Sharing database was examined from 2005 to 2012 for patients with cfLVAD and pulsatile flow LVAD (pLVAD). These 2 cohorts were compared with patients who did not receive LVAD.ResultsOf 16,476 total orthotopic heart transplantations, 3270 (19.8%) were performed on patients with an LVAD as a bridge to transplantation. The cfLVAD group had the longest total waitlist time (259.6 days) compared with the pLVAD (134.6 days) and non-LVAD (121.7 days) groups (P < .001). The cfLVAD group spent more time in status 1A (44.7 days) than did the pLVAD (32.1 days) and non-LVAD (16.4 days) cohorts (P < .001). The median waitlist survival was better for the cfLVAD group (1234.0 days) than in the pLVAD (441.0 days) and non-LVAD (471.0 days) groups (P < .001). The cfLVAD recipients were older, had a greater body mass index, and more often had diabetes than did pLVAD and non-LVAD patients. The cfLVAD cohort received hearts from older, more often male donors, with a greater body mass index. Post-transplant survival was not significantly different among the 3 groups on Kaplan-Meier analysis (P = .12).ConclusionsDespite being older, less favorable recipients, the cfLVAD patients spent more time in status 1A and had greater waitlist survival. This might allow cfLVAD patients to receive preferred donor hearts, which might allow for better post-transplant survival

Impact of low donor to recipient weight ratios on cardiac transplantation

BackgroundInternational Society of Heart and Lung Transplantation guidelines for adult heart transplantation (HT) suggest a donor to recipient body weight ratio (WR) of greater than 0.8. For female to male transplants, a WR of greater than 0.9 is recommended.MethodsThe United Network for Organ Sharing database was examined for adult HT from 1999 to 2011. Controls with a WR of 0.9 or greater (normal donor to recipient weight ratio) were compared with patients with a WR of 0.6 to 0.89 (WRL) and a WR of less than 0.59 (WRVL). The primary measured outcome was survival.ResultsOf the 21,928 patients undergoing HT, 14,592 (66.6%) were performed with a normal donor to recipient weight ratio, 7212 (32.9%) were performed with WRL, and 124 (0.6%) were performed with WRVL. In male donor to male recipient, male donor to female recipient, and female donor to female recipient HT, the use of WRL did not influence median survival (P = .3621) and was not associated with increased mortality (P = .7273). In female donor to male recipient HT, WRL was associated with decreased median survival (435 days, P = .0241) and was associated with increased mortality (hazard ratio, 1.201; P = .0383).ConclusionsHT can be safely performed using WRL donors between sex-matched and male to female transplants. However, in female to male transplants, WRL donors are associated with decreased survival. Although clinical circumstances will guide decision making, consensus criteria may be revisited to liberalize the pool of acceptable donors in an era of unprecedented donor shortage