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J Thorac Cardiovasc Surg 2006;131:1212
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

Columbia University, College of Physicians and Surgeons, Department of Cardiothoracic Surgery, New York, NY

We thank Dr Ashraf for his comments on our recent article concerning the use of left ventricular assist devices (LVADs) in patients with chronic congestive heart failure. ¹ His letter invites us to discuss several important points.

First, to clarify the device type used predominantly at our center and used exclusively in our study, we favor the HeartMate XVE (single-lead vented electric) LVAD (Thoratec Corp, Pleasanton, CA) for its relative ease of implantation, durability, and lack of need for systemic anticoagulation. Our long-term experience with this device has paralleled an evolution in design, resulting in improved bridge-to-transplant and posttransplant survival rates. ²

Next, we could not agree more with Dr Ashraf's observation that the timing of transplantation following LVAD insertion plays a critical role in determining survival. Our own unpublished data show near normalization of blood urea nitrogen, creatinine, and liver function values at approximately 3 months of support time, bolstering the concept of enhanced end-organ perfusion by the LVAD. Moreover, the smooth transition to cardiac rehabilitation and nutritional optimization throughout the recovery period are of critical importance.

Although we do not employ the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system ourselves, we use similar clinical and laboratory-based parameters to select LVAD candidates. All patients referred for LVAD are generally refractory to maximal medical therapy, which often includes the use of intravenous inotropes, vasopressors, and intra-aortic balloon pumps. Exclusion is therefore done on the basis of such factors as ventilatory status, elevated pulmonary pressures, and prolonged prothrombin time.

Despite the physiologic benefits of LVADs, even as they apply to the right ventricle, right heart failure (RHF) occurs in approximately 15% to 20% of patients postoperatively. ^3,4 Multiple studies have sought to identify demographic and hemodynamic risk factors predictive of the development of RHF, but in practice, these parameters often exhibit variable outcomes. Although the best treatment for RHF is avoidance, when it does become manifest, a low threshold should be maintained to promptly start inotropic (ie, milrinone) and pulmonary vasodilator (ie, nitric oxide) therapy, with a right ventricular assist device close at hand.

	References

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1. Dang NC, Topkara VK, Kim BT, Mercando ML, Kay J, Naka Y. Clinical outcomes in patients with chronic congestive heart failure who undergo left ventricular assist device implantation. J Thorac Cardiovasc Surg 2005;130:1302-1309.[Abstract/Free Full Text]
   
2. Morgan JA, John R, Rao V, Weinberg AD, Lee BJ, Mazzeo PA, et al. Bridging to transplant with the HeartMate left ventricular assist device. The Columbia Presbyterian 12-year experience. J Thorac Cardiovasc Surg 2004;127:1309-1316.[Abstract/Free Full Text]
   
3. Goldstein DJ, Oz MC, Rose EA. Implantable left ventricular assist devices. N Engl J Med 1998;339:1522-1533.[Free Full Text]
   
4. Frazier OH, Rose EA, Macmanus Q, et al. Multicenter clinical evaluation of the HeartMate 1000 IP left ventricular assist device. Ann Thorac Surg 1992;53:1080-1090.[Abstract]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nicholas C. Dang Yoshifumi Naka Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Dang, N. C. Articles by Naka, Y. Search for Related Content PubMed Articles by Dang, N. C. Articles by Naka, Y. Related Collections Related Article