Left ventricular assistance from bridge to transplantation to destination therapy. The Pavia experience

Objective The increasing number of patients awaiting heart transplant and the shortage of donors led to the development of a variety of left ventricular assist devices (LVAD). We analyse our experience in order to evaluate the efficacy of LVAD as bridge to transplant and the feasibility of permanent implantation. Patients The data are drawn from our experience on 50 patients, implanted with the Novacor LVAD and from a limited series of 4 patients implanted with a Lion Heart totally implantable permanent LVAD. Results Seventeen patients died on the device, 32 underwent heart transplant (9 died after transplant) and one is still on device. The causes of death were mostly related to cerebrovascular events or multi-organ failure. Cardiac output, wedge pressure, pulmonary vascular resistance and mean pulmonary pressure improved significantly. Cerebrovascular complications occurred mostly during the first 3 months of assistance, whereas the incidence of infections remained constant during the follow-up period. With a mean time of assistance of 211 days, we had only two cases of device malfunction. The four Lion-Heart patients experienced a clear improvement in hemodynamics but at a price of a significant complication rate. Three of them died after 418, 105 and 380 days of assistance. Device malfunction was observed in two cases. Conclusions LVAD Novacor has shown good hemodynamic improvement and reliable mechanical performance and long-term bridging can be considered fairly safe since most complications seem to occur within the first 90 days. Destination therapy with totally implantable devices seems to need further engineering and technical development.