Ann Thorac Surg 1996;61:1739
© 1996 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Bernard Hausen, MD
Division of Thoracic and Cardiovascular Surgery, Surgical Center, Hannover Medical School, D-30623 Hannover, Germany
See also page 1734.
Anyone seriously involved with heart transplantation after the use of assist devices is certainly very much aware of the tremendous difficulties encountered and how moribund these patients often are. Therefore the group from Ottawa must be congratulated on the immense efforts and achievements in this respect.
Masters and associates have pointed out that the majority of assist devices installed were in patients presenting with profound acute cardiovascular collapse. In this nonelective situation bridging systems are the only feasible alternative. Certain standardized and irrevocable selection criteria should apply such as age, the presence of multiorgan failure, neurologic events, or systemic infection. In general these should be the same selection criteria as used for evaluation of prospective heart transplant candidates, as weaning from support systems is rarely possible. The significantly lower age of patients supported with total artificial hearts in this analysis reflects these prerogatives.
Once the patient is stabilized on the assist system the physician must decide if heart transplantation is feasible and, if it is, when to transplant. In a time of donor organ scarcity one must critically assess if we can afford a hospital survival of 60% or less. A constant reevaluation of patient status and the presence of exclusion criteria for transplantation must be performed on a daily basis. Infection was present in almost 50% of the patients on a total artificial heart in this study. As the mean support time was extremely short (mean support time, 8 ± 2 days), this implies that transplantation was often performed in infected patients, and this is underlined by the fact that infection remained the most serious complication after transplantation. In previous studies Frazier and Pennington have beautifully shown how infectious events, renal failure, or neurologic sequelae can be treated or convalescence awaited in patients on total artificial hearts. Support times of weeks to months may be necessary to convert a poor candidate to one in whom hospital survival of nearly 90% after transplantation can be expected. If, despite the use of bridging devices, the patient cannot be stabilized and the number of complications is increasing, then heart transplantation should not be an option. We are responsible, not only for this special patient cohort, but for the entire waiting list and must therefore attempt optimal use of donor organs.
Related Article
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Cardiac Transplantation After Mechanical Circulatory Support: A Canadian Perspective
- Roy G. Masters, Paul J. Hendry, Ross A. Davies, Stuart Smith, Christine Struthers, Virginia M. Walley, John P. Veinot, Tofy V. Mussivand, and Wilbert J. Keon
Ann. Thorac. Surg. 1996 61: 1734-1739.
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