The history of mechanical circulatory support (MCS) parallels that of cardiac surgery and began with the introduction of the Gibbon bubble oxygenator.1 That revolutionary device opened up the field of cardiac surgery and was one of the major medical advances of the last century. Soon after the use of cardiopulmonary bypass (CPB) became commonplace, failure to wean from CPB became recognized as a problem whose solution required temporary cardiac support to enable postcardiotomy cardiac recovery. Spencer and coworkers utilized postoperative femoral CPB in 3 patients, one of whom survived and ushered in the modern era of temporary MCS.2 This was soon followed by the use of the first extracorporeal mechanical assist device by DeBakey et al. in 1964 and the subsequent development of the intra-aortic balloon counterpulsation device, variations of which are still in use today. Kantrovitz, Cooley, Oyer, Devries, and others were responsible for other notable firsts including the first successful bridge to transplant (BTT) and first successful total artificial heart (TAH) implant.3–7 Notable clinical landmarks in the history of MCS are shown in Table 51-1. In this chapter, we review the major indications for MCS as well as the various options available.
Table 51-1:Clinical Milestones in the Development of Mechanical Circulatory Assistance ||Download (.pdf) Table 51-1: Clinical Milestones in the Development of Mechanical Circulatory Assistance
|Year ||Investigator ||Type of Device ||Comments |
|19531 ||Gibbon ||Heart–lung machine ||Closure of ASD in human |
|19592 ||Spencer ||Femoral bypass ||First case of successful recovery postcardiotomy |
|19633 ||DeBakey ||Pneumatic paracorporeal VAD ||Postcardiotomy failure; 4 days survival |
|19684 ||Kantrovitz ||IABP ||Clinical application of IABP |
|19695 ||Cooley ||Liotta TAH ||Successful bridge to transplant but patient died posttransplant |
|19846 ||Oyer ||Novacor ||Successful bridge to transplant, patient survived |
|19807 ||DeVries ||Jarvik TAH ||First human implant |
Indications for Mechanical Circulatory Support
Generally speaking, there are three primary indications for the use of MCS: “bridge to recovery” (BTR), “bridge to transplant” (BTT), and “destination therapy” (DT). Data on MCS devices implanted in the United States are kept by the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS).8 According to the second INTERMACS annual report that provides information on FDA-approved device implantations from 2006 to 2009, the most common indication for MCS was BTT (45.4 percent), followed by DT (9.2 percent), and BTR (2.3 percent) (Fig. 51-1). Bridge to candidacy for transplantation, or “bridge to decision” is a fourth category that has emerged and includes patients whose candidacy for transplantation has not been decided for medical or social reasons. This accounted for 41.9 percent of all device implantations during this time period. Within each of these categories, specific device therapy can be broken down into short-term (days to weeks) and long-term (weeks or longer) therapy.