Ann Thorac Surg 2009;88:1826-1827. doi:10.1016/j.athoracsur.2009.09.043
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Louis Samuels, MD
The Lankenau Medical Center, Medical Science Bldg, Suite 280, 100 Lancaster Ave, Wynnewood, PA 19096
(Email: samuelsle{at}aol.com).
It has been more than 45 years since the inception of using a ventriclar assist device (VAD) after aortic valve surgery (the Starr-Edwards valve; Edwards Laboratories, Inc, Santa Ana, CA) was clinically introduced by Domingo Liotta and Ernest Stanley Crawford on July 18, 1963 in Houston [1]. It is fortuitous that the article by Gregoric and colleagues [2] on the use of the TandemHeart (CardiacAssist Inc, Pittsburgh, PA) as a rescue therapy for patients with critical aortic valve stenosis comes from the same institution. Just like the Texas Heart Institute (THI), the evolution of the VAD in the four decades is remarkable; while the THI got larger, the VADs got smaller.
In this limited experience of 10 profoundly ill patients with critical aortic stenosis, in which the TandemHeart VAD was used perioperatively, 7 patients (70%) had a meaningful survival. Important concepts in this article are the following: (1) 8 of 10 patients had the VAD placed in the catheterization laboratory prior to undertaking surgery, and all of the patients were taken to the operating room (OR) only after hemodynamic stability was re-established at a mean support time of 6.4 ± 3.8 days. It cannot be emphasized enough that the ability to rapidly and effectively stabilize the patient preoperatively with mechanical circulatory support is directly related to a more favorable outcome; the collaboration between cardiology and cardiac surgery in this regard is worthwhile [3]; (2) the two patients who received the VAD after the valve surgery (both of whom were undergoing cardiopulmonary resuscitation on the way to the OR) died on days 8 and 21, respectively; the lesson here is not a new one, and the experience with any device would likely have a similar outcome in patients such as these (ie, the ability to avoid this situation is obvious); (3) The TandemHeart (unlike the Impella, which requires crossing of the aortic valve to reside directly in the LV) can be used safely in the setting of aortic stenosis, mechanical aortic prostheses, and in cases with significant ascending aortic or arch disease, because these areas are avoided by virtue of its design; and unlike extracorporeal membrane oxygenation, the TandemHeart affords better left ventricular unloading by virtue of its inflow tip residing in the left atrium. As an aside, an oxygenator can be inserted in the TandemHeart and was used in one case resulting in restoration of neurologic function.
In short, this article introduces us to an important role for a unique device that has translated into lives saved.
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References
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- Liotta D. Early clinical application of assisted circulation Tex Heart Inst J 2002;9:229-230.
- Gregoric ID, Loyalka P, Radovancevic R, Jovic Z, Frazier OH, Kar B. TandemHeart as a rescue therapy for patients with critical aortic valve stenosis Ann Thorac Surg 2009;88:1822-1827.[Abstract/Free Full Text]
- Samuels LE, Holmes EC, Hagan K. Cardiogenic shock: collaboration between cardiac surgery and cardiology subspecialities to bridge to recovery Ann Thorac Surg 2007;83:1863-1864.[Abstract/Free Full Text]
Related Article
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TandemHeart as a Rescue Therapy for Patients With Critical Aortic Valve Stenosis
- Igor D. Gregoric, Pranav Loyalka, Rajko Radovancevic, Zoran Jovic, O.H. Frazier, and Biswajit Kar
Ann. Thorac. Surg. 2009 88: 1822-1826.
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