Long-Term Management of Pulsatile Extracorporeal Left Ventricular Assist Device

Heart transplantation provides considerable survival benefits for patients with end-stage heart failure, but it is available for only a small fraction of such patients all over the world due to donor shortage. Therefore, many heart transplant candidates require long-term support by a left ventricular assist device (LVAD) while they await transplantation. However, the long-term LVAD support can result in serious complications such as cerebrovascular accident (CVA) and infection, which are the leading cause of death and the primary reason for elimination from transplant eligibility in patients supported by LVAD (Rose EA et al., 2001; Holman WL et al., 2009). In Japan, only less than 100 organ transplants from brain-dead donors have been performed over the past 10 years. The mean waiting period for heart transplant candidates after LVAD surgery frequently exceeds 2 years. In addition, the only available LVAD covered by the National Health Insurance System in Japan is pulsatile extracorporeal LVAD (ToyoboLVAS®; Nipro, Tokyo, Japan). Implantable LVADs have not yet been approved and are still under clinical trials, awaiting approval by the Ministry of Health, Labour and Welfare as of October 2010. Toyobo-LVAS® was primarily designed for short-term support, but it is used in Japan over the long term as a ‘bridge-to-transplant’ device (Figure 1). Patients supported by pulsatile extracorporeal LVAD cannot be discharged from the hospital, and cannot leave the intensive care ward without attendant medical doctors. Some patients required to be supported by such device for 4 years until being transplanted. Given these circumstances, the long-term management skills of Japanese cardiologists for overcoming “extracorporeal pulsatile” LVAD–related complications have improved over time, with the 1-year survival now being 82% (Sasaoka T et al., 2010). The extracorporeal pulsatile LVAD is the devise that is not utilized in a first line anymore in a world except for Japan. However, CVA and infection, on which we have paid considerable attention during long-term management of extracorporeal pulsatile LVAD, still remain to be important complication even in the era of new generation continuous flow devises. Therefore, we believe that our delicate care for such complication to accomplish long-term survival in patients supported by extracorporeal pulsatile LVAD is worthwhile information even today. In this chapter, we focused on the management strategies of CVA and infection in patients with extracorporeal pulsatile LVAD according to our past 10 years experience.