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Heart failure (HF) remains one of the most common causes of death in the United States. Preventive measures and treatment options for HF have, however, improved significantly. The 2005 ACC/AHA guidelines introduced a comprehensive and systematic method of assessing and managing patients with risk factors and those with HF.1 The suggested staging system is ambitiously inclusive, covering a wide range of patients with cardiovascular problems. It categorizes patients into Stages A (at high risk for HF but without structural heart disease or symptoms of HF) to D (refractory HF requiring specialized interventions). Surgical interventions play a significant role at each stage, and their role becomes more important as the stage advances. The surgical options described in the guidelines include, but are not limited to, coronary artery bypass grafting (CABG), valve replacement or repair, ventricular restoration surgery, heart transplantation, permanent mechanical support, and experimental surgery. A wide range of cardiac surgical procedures are covered, implying that HF is becoming one of the most important fields for cardiac surgeons.
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Among the available surgical interventions for HF, mechanical circulatory support (MCS) is distinct from the others in that it, at least partially, replaces the pump function of the failing heart, similar to heart transplantation. Unlike heart transplantation, however, it does not rely on a human donor supply, which is a well-known limiting factor. As technologic advances have accrued, MCS has evolved into a reliable and well-described treatment option.
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MCS may include intra-aortic balloon pump (IABP), ventricular assist device (VAD), total artificial heart (TAH), cardiopulmonary support (CPS) such as venoarterial (VA), extracorporeal membrane oxygenation (ECMO), and additional circulatory support systems. In this chapter we will focus on VAD, TAH, and CPS. Among these, VAD therapy as a method of ventricular support and TAH as a replacement of the heart are gaining particular attention. In this chapter, VAD therapy will be discussed in detail in relationship to other technologies.
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Mechanical support of the cardiopulmonary system was first clinically introduced by John Gibbon in 1953, when he first successfully employed cardiopulmonary bypass for the repair of an atrial septal defect.2 In 1963, DeBakey implanted the first VAD in a patient who suffered a cardiac arrest following aortic valve replacement. The patient subsequently died on postoperative day 4. In 1966, DeBakey reported the first successful bridge to recovery with implantation of a pneumatically driven VAD in a patient suffering from postcardiotomy shock. The patient was supported for 10 days, and ultimately survived to discharge.3 Soon thereafter, Cooley reported the first successful bridge to transplantation (BTT) using a pneumatically driven implantable artificial heart.4 During this time, the National Heart, Lung and Blood Institute (NHLBI) began funding initiatives to further the development of VADs and a TAH. DeVries and colleagues reported the successful implantation of the Jarvik-7-100 TAH in 1984.5 Despite initial success, a high incidence of thromboembolic and infectious complications led to a moratorium on the use of the ...