Ann Thorac Surg 2009;88:1466-1467. doi:10.1016/j.athoracsur.2009.08.028
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Hans Joachim Geissler, MD
Department of Cardiovascular Surgery, University of Freiburg, Hugstetter Str. 55, Freiburg, 79106 Germany
(Email: joachim.geissler{at}uniklinik-freiburg.de).
Treatment of cardiogenic shock remains a major challenge for all medical specialties who are involved. Appropriate use of inotropes (including new drugs such as calcium sensitizers) is the established line of treatment, and this treatment may be combined with intraaortic balloon pump support, if needed. However, there remains a significant number of patients in whom these measures are not sufficient to stabilize the circulatory system. Mechanical circulatory support can be a lifesaving option in these selected patients. Until some time ago, there were only two options for this scenario: either (1) extracorporeal membrane oxygenation (ECMO) for short-term support or (2) a full-scale, long-term ventricular assist device, which implies substantial consumption of healthcare resources. This situation has changed in several ways. First, there are now a number of devices available for this purpose from a simplified ECMO set-up over microaxial flow pumps to systems that require trans-septal cannula placement in the left atrium. Second, as many of these devices can be applied percutaneously, the invasiveness of implantation has decreased to a point at which it is no longer an exclusively surgical domain. Nevertheless, data on patient selection criteria, timing of implantation, and patient outcome are mostly limited to institutional reports on rather minor numbers of patients. In summary, for the treatment of cardiogenic shock with mechanical circulatory support, we do not suffer from a lack of devices, but from a lack of evidence-based concepts and treatment algorithms. The interesting and impressive work presented by Brinkman and colleagues [1] describes the use of a percutaneous VAD system in the setting of a cardiac transplant program. The investigated system was the TandemHeart (Cardiac Assist Inc, Pittsburgh, PA); this device uses an inflow cannula that is implanted in the left atrium by a trans-septal approach, which requires the use of sophisticated fluoroscopy equipment that is only available in a cardiac catheterization or angiography laboratory. The results are promising, and one of the important issues addressed in the article is the "bridge-to-decision" as an indication for mechanical circulatory support. However, the feasibility of a device that requires transfer of an already unstable patient to the cardiac catheterization laboratory, and roughly an hour of implantation time, remains to be evaluated in comparison with devices that can be implanted within minutes at the bedside, such as percutaneous ECMO.
In summary, treatment of cardiogenic shock with mechanical circulatory support is a challenging, exciting, and expanding field. The vast experience cardiac surgeons have in the use of extracorporeal circulation and in the treatment of its complications should make them an ideal partner in the interdisciplinary treatment of cardiogenic shock. Cardiac surgeons need to define their place in the care of these critically ill patients, not in competition, but in cooperation with intensivists and cardiologists.
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- Brinkman WT, Rosenthal JE, Eichhorn E, et al. Role of a percutaneous ventricular assist device in decision making for a cardiac transplant program Ann Thorac Surg 2009;88:1462-1467.[Abstract/Free Full Text]
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Role of a Percutaneous Ventricular Assist Device in Decision Making for a Cardiac Transplant Program
- William T. Brinkman, Jed E. Rosenthal, Eric Eichhorn, Todd M. Dewey, Mitchell J. Magee, Darinka S. Savor, Angela G. Riley, Syma L. Prince, Christine M. Worley, Morley A. Herbert, and Michael J. Mack
Ann. Thorac. Surg. 2009 88: 1462-1466.
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