Ann Thorac Surg 1997;64:1762-1763
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Walter E. Pae, Jr, MD
Section of Cardiothoracic Surgery, Penn State Geisinger Health System, PO Box 850, Hershey, PA 17033-0850
See also page 1757.
Great progress has been made in the development and clinical use of ventricular assist devices (VADs). The ability of VADs both to support the circulation in the potentially reversible situation and to provide a bridge to orthotopic transplantation is unquestioned. The clinical outcomes when the devices are used as a bridge to transplantation have been no less than spectacular. However, the results of VADs in patients with postcardiotomy cardiogenic shock have been disappointing. What this report underscores, perhaps more than is apparent, is that the selection of patients for support is critical to success.
Previous reports have indicated that rates of subsequent transplantation and ultimate hospital discharge in device-dependent postcardiotomy patients who are transplant candidates are nearly identical to those obtained when VADs are used as a standard bridge to transplantation. The authors' excellent clinical results confirm these findings in a very select group of patients with postcardiotomy cardiogenic shock. The authors also present an algorithm with which to manage such patients that should be useful in any program that performs cardiac surgical procedures.
The widespread availability of short-term mechanical support systems approved by the Food and Drug Administration should allow for timely (early) intervention when postcardiotomy cardiogenic shock is unforeseen in patients who have normal ventricular function before operation or those who have severely depressed preoperative left ventricular function and are at high risk. Networking with a transplant center allows rapid patient screening and further access to implantable or long-term VAD support for patients who have no contraindications to orthotopic cardiac transplantation and in whom recovery of myocardial function is not expected. When patients are considered to be appropriate transplant candidates before undergoing high-risk cardiac operations with VAD backup, the wider availability of implantable devices provides an additional therapeutic option in selected patients in both transplant centers and nontransplant centers that have network arrangements.
Certainly, early intervention, patient selection, and a well-thought-out treatment protocol are the keys to success, because most complications are related to the patient rather than the device. As clinical experience accumulates, it is likely that there will be less morbidity and improved survival when prompt circulatory support is provided with VADs compared with marginal support provided with polypharmacy and intraaortic balloon counterpulsation in patients with postcardiotomy cardiogenic shock. Last, it is hoped that future implantable VADs will be offered as destination therapy to device-dependent patients who are not transplant candidates as current clinical trials unfold, further solidifying the safety and efficacy of these devices in the treatment of end-stage congestive heart failure.
Related Article
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Improved Results for Postcardiotomy Cardiogenic Shock With the Use of Implantable Left Ventricular Assist Devices
- Joseph J. DeRose, Jr, Juan P. Umana, Michael Argenziano, Katharine A. Catanese, Howard R. Levin, Benjamin C. Sun, Eric A. Rose, and Mehmet C. Oz
Ann. Thorac. Surg. 1997 64: 1757-1762.
[Abstract]
[Full Text]
