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Ann Thorac Surg 2005;79:66-73
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Body Mass Index and Outcomes After Left Ventricular Assist Device Placement

^a Cardiology Division, Center for Education and Research in Therapeutics, and Transplant Center, Vanderbilt University, and the Geriatrics Research, Education, and Clinical Center, Nashville VAMC, Nashville, Tennessee, USA
^b World Heart Inc, Oakland, California, USA
^c Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
^d Department of Cardiothoracic Surgery, University of Maryland and Baltimore VAMC, Baltimore, Maryland, USA

Accepted for publication June 11, 2004.

^* Address reprint requests to Dr Butler, Cardiology Division, 383-PRB, Vanderbilt University Medical Center, Nashville, TN 37232 (E-mail: javed.butler{at}vanderbilt.edu).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

 
BACKGROUND: Although extremes of body mass index (BMI) are associated with decreased survival after cardiac transplantation, its association with outcomes after left ventricular assist device (LVAD) implantation is not known. This issue is especially important as LVADs are now approved as destination therapy for advanced heart failure patients who are not transplant candidates. In this study, we assess the association between BMI and outcomes after LVAD implantation.

METHODS: A total of 222 patients who underwent LVAD placement (190 bridge-to-transplant [BTT] and 32 destination therapy) were divided into four groups based on BMI (kg/m²) quartiles (group 1, <22.9; group 2, 22.9 to 26.3; group 3, 26.4 to 29.4; and group 4, >29.4) and were compared for outcomes.

RESULTS: Eighty-four patients died on LVAD support. Six- and 12-month survival on LVAD for the four groups was 35%, 60%, 65%, and 73%, and 26%, 34%, 50%, and 66% (both p < 0.01), respectively. Similar trends were seen for the composite endpoint of survival on LVAD and within 30 days posttransplant among BTT patients. Infectious, neurological, respiratory, or bleeding complications were not related to BMI. Patients with higher BMI tended to have a greater risk of reoperations (43%, 49%, 53%, and 61%, p = 0.06) and renal complications (16%, 33% 23%, 43%, p = 0.03). Age and history of thoracotomy were independently associated with mortality whereas higher BMI was not. Survival was worst for patients with lowest BMI.

CONCLUSIONS: Higher BMI did not adversely affect survival after LVAD implantation and therefore relative obesity should not be considered a contraindication for LVAD placement. Further work is needed to understand and manage risks for low BMI patients.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

 
The limitations of medical therapy combined with the donor organ shortage and strict selection criteria for cardiac transplantation leave many end-stage heart failure patients without an effective therapeutic alternative [1–5]. The first randomized clinical trial assessing a left ventricular assist device (LVAD) as "destination therapy" demonstrates that mechanical circulatory support can successfully address this need in highly selected patients ineligible for cardiac transplantation, with significant survival benefit for LVAD recipients compared to standard medical therapy [6]. This trial led to approval by the Food and Drug Administration (FDA) and by the Center for Medical Services (CMS) for the use of LVADs as for the destination therapy indication [7, 8]. However, LVAD implantation with subsequent care is expensive. To optimize the cost-effectiveness of this therapy in the context of constrained health care resources, and minimize futile application, data are necessary that will allow practitioners to identify destination LVAD therapy candidates who can reasonably be projected to have acceptable outcomes.

In this context, malnutrition – in the form of both protein-calorie deficiency and obesity – is generally recognized as a major risk factor for surgery, and might thus be expected to influence efficacy of LVAD therapy. Obesity is epidemic [9], and is associated with worse perioperative outcomes for surgical procedures in general and with higher mortality rates after heart transplantation [10, 11]. Although transplant candidacy criteria vary among centers, severe obesity is considered a contraindication due to higher mortality post-transplant [3, 11–14]. While nutritional factors such as low albumin or prealbumin identify patients at increased surgical risk, low body mass index (BMI) has not traditionally been used as a criterion to exclude heart transplantation.

An association between BMI and LVAD outcomes has not previously been described. In this study, we assessed whether recipient BMI is correlated with the mortality and major morbidity among patients undergoing Novacor (WorldHeart Inc, Ontario, Canada) LVAD implantation. In particular we reasoned that, if low or high body mass index (BMI) is associated with acceptable LVAD outcomes, this approach could provide a therapeutic alternative for cachectic or overweight and obese patients without diverting scarce hearts from lower risk patients. This issue is especially important because the prevalence of overweight and obese in the United States population continues to rise [9].

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

 
Patient Population
The study population for this retrospective investigation consisted of 222 patients with advanced heart failure who underwent placement of a Novacor LVAD in the US from 1996 to 2003. The patients were drawn from two separate FDA-approved clinical trials of the Novacor device. One hundred ninety patients underwent LVAD placements as bridge-to-transplant in 20 centers (data maintained in WorldHeart, Inc. registry on patients from bridge-to-transplant FDA trial). Another 32 patients underwent LVAD placement as destination therapy within the multicenter INTrEPID trial in 10 centers (investigation of nontransplant-eligible patients who are inotrope dependent). Data on both patient groups was abstracted from study reporting forms and entered into a registry database at WorldHeart Inc.

Patients were divided into four groups based on their body mass index (BMI) quartile distribution: group 1 (BMI < 22.9 kg/m²), group 2 (BMI 22.9 to 26.3 kg/m²), group 3 (26.4 to 29.4 kg/m²), and group 4 (BMI > 29.4 kg/m²). These groups were compared for morbidity and mortality after LVAD implantation.

Outcomes and Definitions
The primary study outcome was survival after LVAD placement. This was assessed as proportion of patients within each BMI quartile alive at 30, 180, and 365 days postimplantation. Because a majority of the LVADs currently are placed as a bridge-to-transplantation, we also assessed the importance of BMI in these patients in relation to device explant at the time of transplantation, by assessing the composite end point of mortality either on LVAD or within 30 days after transplantation. We also assessed mortality alone in the bridge to transplant patients to rule out the possibility of misleading results based on two separate databases. These results were similar to the combined database. In order to increase the power to detect significant differences, all subsequent analyses were therefore performed on the combined database.

Cause of death was studied by dividing deaths into the following categories: cardiovascular, neurologic, infectious, multisystem organ failure, miscellaneous, and unknown. The following complications were also compared between the four groups.

NEUROLOGIC
Included transient ischemic attack, embolic stroke, hemorrhagic stroke, thrombotic stroke, seizures, and metabolic encephalopathy. Considering the special significance of thromboembolism and anticoagulation issues among patients undergoing LVAD placement, we also specifically studied the incidence of transient ischemic attack, embolic stroke, and hemorrhagic stroke among the four groups.

INFECTIOUS
Any positive blood or tissue culture requiring antibiotic therapy. We also specifically studied pump pocket or driveline infections and systemic sepsis.

RESPIRATORY
Ventilator support for more than 5 days for the index operation or any other unplanned intubation thereafter excluding reoperations.

RENAL
Requirement of dialysis/hemofiltration or elevation in serum creatinine to more than 3.5 mg/dL. Because patients with baseline significant renal insufficiency may be selected for destination LVAD therapy but not for transplantation, this analysis was restricted to the 190 patients who underwent LVAD placement as bridge-to-transplantation only.

BLEEDING
Bleeding in any organ system requiring greater than 5 units of packed red blood cell transfusions within a 24-hour period.

REOPERATION
Any surgery required after LVAD implantation, excluding transplantation. In order to differentiate reoperations for early postoperative complications from other surgical procedures, we also studied the proportion of reoperations before and after 7 days of LVAD implantation. Specific indications for reoperation were not available.

Statistical Analysis
Univariate analyses were performed to assess associations between patient characteristics and the various patient groups based on BMI using ² tests (testing for linear trends) for categorical and analysis of variance (ANOVA) for continuous variables. Complications after LVAD implantation were compared between the four groups using the same analytic approach. The Kaplan-Meier survival method was used to assess both overall survival and the composite endpoint of survival on LVAD and within 30 days of transplantation. Log rank statistics were performed to assess statistical significance between survival differences among the four groups. Cox regression analyses were performed to assess the independent predictors of survival and to calculate odds ratios (OR) and 95% confidence intervals (CI). The following characteristics were studied as potential predictors: age, gender, race, etiology of heart failure, prior history of hypertension, diabetes, thoracotomy, abdominal surgery, smoking, transient ischemic attack, stroke, several serum chemistries, and hemodynamics. Variables with missing values for more than 15% of the study sample were excluded from consideration including pulmonary capillary wedge pressure, serum albumin, glucose, and hemoglobin.

A two-tailed p value of 0.05 was used to designate statistical significance. All p values equal to or less than 0.20 are shown in the results, the remaining are designated as nonsignificant (NS). Categorical variables are presented as proportions and continuous variables as mean ± standard deviation (SD). All analyses were performed using SPSS for Windows Release 11.5 (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

 
Patient Characteristics
The average age of the study population was 51 ± 13 years. Over 80% of the patients were males and white. There was almost an equal split between ischemic and nonischemic etiology for heart failure and one quarter of the patients had diabetes. Other patient characteristics are shown in Table 1.

The prevalence of several comorbidities differed among the four patient groups. Diabetes, hypertension, and transient ischemic attack increased in prevalence with increasing BMI, whereas prior thoracotomy was most common in patients within the lowest BMI quartile. Hemodynamic and laboratory values for the four groups are summarized in Table 1.

Complications After LVAD
Except for renal complications and reoperations, none of the complications were significantly different between the four groups as shown in Table 2. Neither the rate of overall infection nor pump pocket or drive line infection specifically was associated with BMI. There was a trend toward increased need for reoperation among patients within the highest BMI quartile (43%, 49%, 53%, and 61%, p = 0.06). When stratified by time postimplantation, there was no significant relationship between BMI and a higher rate of reoperation, either within the first 7 days after LVAD placement or thereafter. Renal complications occurred more frequently among patients in the highest BMI quartile (20%, 33%, 24%, and 43%, p = 0.03).

View larger version (21K): [in this window] [in a new window]   Fig 1. Survival associated with left ventricular assist device therapy, stratified by BMI. Survival was better for patients in the higher BMI groups as compared to those within the lowest BMI. (BMI = body mass index.)

Cause of Death
The cause of death for patients who died while on LVAD support included: neurologic 27%, multi-system organ failure 18%, infections 16%, cardiovascular 11%, miscellaneous 11%, and unknown 17%. There was no linear significant difference between the four groups based on BMI with respect to the cause of death as depicted in Figure 2.

View larger version (53K): [in this window] [in a new window]   Fig 2. Cause of death stratified by body mass index quartiles.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

In this context our data begins to address the role of nutritional derangements to LVAD outcomes, using BMI as a proxy. Nutritional disorders, both cachexia and being overweight, are common among those with end-stage heart failure, and thus potentially important to development of clinical selection guidelines. Are patients at either extreme of BMI at a higher risk of mortality after LVAD implantation?

In contrast to results from heart transplantation and other surgical procedures, we did not find any independent association between increased BMI and mortality after LVAD placement. In fact survival in the fourth quartile (BMI > 29.4 kg/m²) was significantly better than in the lowest BMI quartile, the group with the worst overall survival. Moreover, with respect to several common complications associated with LVAD implantation, only reoperation and renal complications were more common in overweight and obese patients. Although major complications were prevalent in all groups, as expected following major surgery in critically ill patients, neither high nor low BMI was particularly associated with an increased incidence of nonlethal infectious, neurologic, respiratory, or surgical complications post-LVAD.

Based on prior studies in other patient populations, we initially hypothesized that obesity would be associated with increased mortality and morbidity after LVAD implantation. Relatively good outcomes in overweight and obese LVAD recipients may be an example of the "risk factor paradox," a term used to characterize the observation that higher cholesterol, weight, and blood pressure are associated with improved outcomes in heart failure patients [18–20]. Similar trends toward improved outcomes at higher BMI are also seen with end-stage renal disease on dialysis, and in certain malignancies [21, 22]. Several hypotheses have been advanced to explain these findings. One possibility includes the potential time discrepancy between competitive risk factors. The survival advantages that exist in obese or hypercholesterolemic heart failure patients may, in the short-term, outweigh the adverse effects of these risk factors on cardiovascular disease in the long-term. Since heart failure patients have a mortality risk that is significantly higher than the general population, the short-term effects of other factors on heart failure mortality, eg, malnutrition, may outweigh the long-term effects of these risk factors on future mortality. Another possibility is the presence of the malnutrition-inflammation complex syndrome, an inverse association between BMI and the intensity of the systemic response to inflammation. Finally, survival bias may play a role. Since patients with heart failure have undergone specific processes of selection and survival, unlike many other patients with cardiovascular risk factors who succumb to diseases like myocardial infarction and die before developing heart failure, their characteristics may not be similar to the general population. Those that did survive despite the risk factors to reach the heart failure "stage" may have other protective factors that otherwise negate the adverse effects of the conventional risk factors.

Relatively higher mortality among the patients in the lowest BMI quartile may represent the influence of cachexia and severe protein-calorie depletion, one manifestation of far advanced heart failure. Heart transplant recipients who are below the normal weight range also have a significantly higher mortality [11]. Together these observations support the hypothesis that restoration of normal hemodynamics is not sufficient to "rescue" a substantial minority of patients with a depleted nutritional state. In consequence, the utility of several interventions need to be explored, including pre- or postoperative intensified nutrition, hormonal manipulations, initiation of device support earlier in the course of disease, and the impact of emerging device support strategies that are less invasive. Each might be expected to yield better results in the group with low BMI. Meanwhile, detailed nutritional, immunologic, and metabolic assessment of the overall population of LVAD patients may reveal whether differences in utilization of protein stores, mobilization of other caloric reserves, or a neurohumoral or inflammatory profile associated with BMI allow overweight end-stage heart failure patients to better tolerate peri-operative stressors than can those who exhibit relative protein-calorie depletion.

Age and prior thoracotomy were associated with worse outcomes after LVAD implantation, and a trend toward significance was seen in association with diabetes. These findings are expected, since age, prior thoracic surgery and diabetes strongly predict adverse surgical outcomes for other cardiac procedures [23–25]. Practice patterns vary widely regarding age as a consideration in transplant eligibility [26]. With the increasing proportion of elderly in the population and a parallel rise in the incidence and prevalence of heart failure in this demographic, our results strongly support the need for specific investigation of age as a risk factor for patients undergoing LVAD implantation. However, this is a moving target since the surgical management of complex reoperations is evolving, as are the devices themselves [26, 27]. Similarly, diabetes management should be easier with a device than on immunosuppressive therapy.

From a policy perspective, if BMI criteria for destination LVAD implantation were to become substantially identical to those for cardiac transplantation, the scope of application for the device alternative would be substantially narrowed, and the needs of a large population of desperate patients left unmet. Rather, studies like this will identify patients at high risk for device therapy or transplantation, based on nutritional or other characteristics. We believe that these patients should most appropriately be cared for in the context of clinical trials designed to better understand their disease, with the aim of developing better approaches to attenuate their suffering, and return them to a valued quality of life.

The most obvious limitation of our study is the range of BMI studied. The highest BMI in our study was 38.3 kg/m², and therefore our observations cannot safely be generalized to patients with BMI greater than 40 kg/m², in whom further study is clearly needed. Moreover, this is a retrospective, secondary analysis of a registry, and not a prospective or randomized study designed to address this specific question. These deficiencies are however partially compensated by completeness of data capture and auditing. Other potentially confounding variables include our finding that patients with BMI greater than 29.4 kg/m² had a higher proportion of white patients. Racial disparity in medical care and outcomes has been previously described in literature [28]. Moreover, the patients in the highest quartile of BMI had the lowest proportion of patients with a previous history of thoracotomy, a known independent risk factor for mortality after transplantation [29]. The relatively low incidence of renal complications in the patients within the lowest BMI quartile may represent a false gap, since the definition of renal dysfunction was based on serum creatinine levels, and not measured creatinine clearance. Because serum creatinine is a function of total body muscle mass, thinner and malnourished patients with similar degree of renal dysfunction are likely to have lower serum creatinine values. Serum albumin data were supposed to be collected but was not reported in the large majority of cases and data on prealbumin were not collected in the registry. Thus we are unable to examine the important hypothesis that these nutritional indices may correlate better than BMI with outcome after LVAD. These indices, along with lean body mass estimates based on morphometric or more sophisticated body composition methods could offer important insights into the mechanism by which malnutrition affects outcome, and if so, could prove useful in gauging the efficacy of interventions to address this risk factor before LVAD implantation. Finally, these data represent the experience with a particular device; different outcomes might be predicted with other devices if size, quality of physiologic support, and ease of insertion are associated with different morbidities.

We conclude that increased BMI is not associated with a higher mortality rate or with an unacceptable risk of major complications, at least for the BMI range represented in this study. Importantly, our findings suggest that patients with BMIs in the lowest quartile should be assessed carefully, and consideration should be given to intensive nutritional rehabilitation around the time of LVAD implantation, particularly for the elderly undergoing reoperation. While more data are needed to investigate the mechanism behind the relationship between BMI and outcomes after LVAD, based on our findings we believe that overweight and obese patients should be considered medically eligible for destination therapy.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

 
WorldHeart, Inc, provided the data for this retrospective study. The primary author performed all analyses independently.

	Footnotes

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

 
Ms Howser and Dr Portner disclose that they have a financial relationship with WorldHeart, Inc.

	References

Top Abstract Introduction Patients and Methods Results Comment Footnotes Acknowledgments References

 

1. Aaronson KD, Mancini DM. Mortality remains high for outpatient transplant candidates with prolonged (>6 months) waiting list time J Am Coll Cardiol 1999;33:1189-1195.[Abstract/Free Full Text]
2. Zaroff JG, Rosengard BR, Armstrong WF, et al. Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations Circ 2002;106:836-841.[Abstract/Free Full Text]
3. Costanzo MR, Augustine S, Bourge R, et al. Selection and treatment of candidates for heart transplantationA statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. Circulation 1995;92:3593-3612.[Abstract/Free Full Text]
4. Gridelli B, Remmuzzi G. Strategies for making more organs available for transplantation N Eng J Med 2000;343:404-410.[Medline]
5. Institute of Medicine Committee to Evaluate the Artificial Heart Program of the National Heart, Lung, and Blood Institute Clinical effectiveness and need for long-term circulatory support1–13In: Hogness JR, VanAntwerp M, editors. The artificial heart: prototypes, policies and patients. Washington, DC: National Academy Press; 1991.
6. Rose EA, Geligns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end stage heart failure N Engl J Med 2001;345:1435-1443.[Medline]
7. US Food and Drug Administration. FDA approves heart assist pump for permanent use. Available at: http://www.fda.gov/bbs/topics/NEWS/2002/NEW00851.html. Accessed on August 11, 2003..
8. Centers of Medicare and Medicaid Services. Decision memo for ventricular assist devices as destination therapy. Available at: http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=79. Accessed on October 7, 2003..
9. Task Force on the Prevention and Treatment of Obesity Overweight, obesity, and health risk Arch Intern Med 2000;160:898-904.[Abstract/Free Full Text]
10. Pasulka PS, Bistrian BR, Benotti PN, Blackburn GL. The risks of surgery in obese patients Ann Int Med 1986;104:540-546.[Abstract/Free Full Text]
11. Grady KL, Naftel DC, Costanzo MR, et al. Are preoperative obesity and cachexia risk factors for post heart transplant morbidity and mortality: a multi-institutional study of preoperative weight-height indicesCardiac Transplant Research Database (CTRD) Group. J Heart Lung Transplant 1999;18:750-763.[Medline]
12. Mudge GH, Goldstein S, Addonizio LJ, et al. 24th Bethesda conference: cardiac transplantation. Task Force 3: recipient guidelines/prioritization. J Am Coll Cardiol 1993;22:21-31..
13. Stevenson LW. Selection and management of candidates for heart transplantation Curr Opin Cardiol 1996;11:166-173.[Medline]
14. Miller LW, Spencer K, Young JB, et al. Report of the consensus conference on candidate selection for heart transplantation-1993 J Heart Lung Transplant 1995;14:562-571.[Medline]
15. National Institutes of Health Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report Obes Res 1998;6(Suppl 2):51S-209S.[Medline]
16. World Health Organization Obesity: preventing and managing the global epidemic: report of a WHO consultation on obesityGeneva, Switzerland: World Health Organization; 1997(publ. no. WHO/NUT/NCD/98.1).
17. Krumholz HM, Murillo JE, Chen J, et al. Thrombolytic therapy for eligible elderly patients with acute myocardial infarction JAMA 1997;227:1683-1688.
18. Horwich TB, Fonarow GC, Hamilton MA, MacLellan WR, Woo MA, Tillisch JH. The relationship between obesity and mortality in patients with heart failure J Am Coll Cardiol 2001;38:789-795.[Abstract/Free Full Text]
19. Horwich TB, Hamilton MA, Maclellan WR, Fonarow GC. Low serum total cholesterol is associated with marked increase in mortality in advanced heart failure J Card Fail 2002;8:216-224.[Medline]
20. Poole-Wilson PA, Uretsky BF, Thygesen K, Cleland JG, Massie BM, Ryden L. Mode of death in heart failure: findings from ATLAS trial Heart 2003;89:42-48.[Abstract/Free Full Text]
21. Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD. Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients Kidney Int 2003;63:793-808.[Medline]
22. Chang AK, Barrett-Connor E, Edelstein S. Low plasma cholesterol predicts an increased risk of lung cancer in elderly women Prev Med 1995;24:557-562.[Medline]
23. Deng MC, Loebe M, El-Banayosy A, et al. Mechanical circulatory support for advanced heart failure: effect of patient selection on outcome Circulation 2001;103:231-237.[Abstract/Free Full Text]
24. Bucerius J, Gummert JF, Walther T, et al. Impact of diabetes mellitus on cardiac surgery outcome Thorac Cardiovasc Surgeon 2003;51:11-16.[Medline]
25. Fonarow GC. How old is too old for heart transplantation? Curr Opin Cardiol 1200;15:97-103..
26. Pierson III RN, Howser R, Donaldson T, et al. Left ventricular assist device implant via left thoracotomy: alternative or adjunct to repeat sternotomy Ann Thorac Surg 2002;73:997-999.[Abstract/Free Full Text]
27. Frazier OH, Myers TJ, Gregoric ID, et al. Initial clinical experience with the Jarvik 2000 implantable axial-flow left ventricular assist system Circulation 2002;105:2855-2860.[Abstract/Free Full Text]
28. Brian D, Smedley AYS, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in health careWashington, DC: Institute of Medicine; 2002.
29. Kirklin JK, Naftel DC, Bourge RC, et al. Evolving trends in risk profiles and causes of death after heart transplantation: a ten-year multi-institutional study J Thorac Cardiovasc Surg 2003;125:881-890.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Peer M. Portner Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Butler, J. Articles by Pierson, R. N. Search for Related Content PubMed PubMed Citation Articles by Butler, J. Articles by Pierson, R. N., III Related Collections Mechanical Circulatory Assistance