Circulatory support exceeding five years with a continuous-flow left ventricular assist device for advanced heart failure patients

A 46-year-old male with ischemic cardiomyopathy was presented with worsening heart failure symptoms and underwent implantation of a HeartMate II CF-LVAD (Thoratec Corporation, Pleasanton, CA, USA) for temporary support until transplant. The postoperative recovery was uneventful, and the patient was discharged from the hospital 23 days after the implant. He resumed an active life style and rehospitalization was only for exchange of a defibrillator battery. Acquired von Willebrand syndrome and hemolysis were observed approximately one year after implant and were treated by a slight reduction in anticoagulation therapy and intravenous Haemate P (coagulation factor VIII). The patient is followed at regular outpatient clinic visits at approximately 2-month intervals. The device pump speed is maintained at 9400 to 9600 RPM and the estimated pump flow is approximately 5.0 L/min. Phenprocoumon (Coumarin) dose is adjusted to achieve an international normalized ratio (INR) of approximately 2.5, and the patient takes 75 mg clopidogrel daily. There have been no problems related to LVAD equipment maintenance. The driveline exit site has been free from infection for the duration of his circulatory support (Fig. 1). This patient has decided to not undergo heart transplant, he exercises at a gym twice a week and works as an office supervisor, and support continues 7.63 years after implantation.

A 56-year-old male with dilated cardiomyopathy presented in October 2005 with NYHA class IV symptoms, pulmonary hypertension, and right heart failure. A pulsatile-flow HeartMate I (XVE-LVAD) was implanted and supported the patient for 13 months until a motor failure, which required the LVAD to be replaced with a HeartMate II device in November 2006. Postoperatively, right heart failure required inotropic support and mechanical ventilation for 10 days. Other postoperative complications included atrial fibrillation, multiple hematomas at the driveline exit site, acquired von Willebrand syndrome, diabetes, knee arthritis and chronic renal insufficiency. The patient left the intensive care unit after 12 days and was discharged from the hospital on postoperative day 49. Since discharge, the patient has required care for ascites, renal insufficiency, and thrombosis of the right jugular vein. The patient is currently receiving dialysis. Although the patient has had multiple complications (unrelated to the device), he has enjoyed an active life during his 7.70 years of mechanical circulatory support, including currently 6.60 years on the HeartMate II CF LVAD. He is retired, and tends to gardening as a hobby.

A 23-year-old male diagnosed with dilated cardiomyopathy presented with acute decompensated heart failure and was being treated with high-dose dobutamine. Due to worsening renal and hepatic function, a HeartMate II was implanted as a bridge to transplant. Upon anesthesia induction, the patient experienced a cardiac arrest, which was promptly treated with cardiopulmonary resuscitation (CPR) and then cardiopulmonary bypass. The LVAD was implanted in the usual manner, and a MEDOS HIA VAD (MEDOS Medizintechnik AG, Stolberg, Germany) temporary right ventricular assist device (RVAD) was also implanted due to intermittent right heart failure. Renal failure with dialysis, postoperative bleeding that required surgical reexploration, hepatic dysfunction and cardiac arrhythmias complicated the postoperative course. After 4 days of RVAD support the device was removed. On postoperative day 17, the patient experienced ventricular fibrillation that was treated with defibrillation and implantation of an implantable cardioverter defibrillator (ICD). Recovery was gradual, dialysis and mechanical ventilation were weaned, and the patient was transferred from the intensive care unit on postoperative day 94. After complete rehabilitation, the patient was discharged from the hospital and lived an active life without serious complications. On December 19, 2010, after 5.46 years of LVAD support, the patient underwent successful heart transplant. Analysis of the explanted LVAD (Fig. 2) showed a clean pump with no accumulated thrombus and very low bearing wear of 0.381 μm over 5.46 years (.070 μm/year) consistent with estimated bearing life of well over 17 years of support as previously reported [4]. In addition, the outflow conduit is clean and without pannus formation in the outflow conduit (Fig. 3).

A 21-year-old male with dilated cardiomyopathy experienced acute decompensation that was treated by implantation of a HeartMate II LVAD. Postoperatively, the patient experienced hemorrhagic bronchitis, pneumonia, pulmonary hypertension, gastritis, and hepatitis that eventually resolved with therapy. After complete recovery and rehabilitation, the patient was discharged from the hospital on postoperative day 23. The patient has had elevated lactate dehydrogenase (LDH) in the range of 400 to 1000 IU/L, but clinically significant device thrombosis has not been detected with careful monitoring. The LVAD is maintained at a speed of 9600 RPM, and the average calculated flow rate is 4.6 L/min. The patient had a very active lifestyle while on LVAD support including regular participation in sports (cycling, soccer). The patient experienced a fractured humerus that occurred during a sporting activity, which was repaired and has healed. Due to the patient’s high activity level, a wire within the external portion of the driveline fractured and required repair. After 5.75 years of LVAD support, the patient underwent successful heart transplant. He continues to actively participate in sports at a fitness center and plays soccer on a German amateur team. Explant analysis showed the pump free of accumulated thrombus and with low bearing wear of 1.163 um over 5.75 years (.202 um/yr.), consistent with findings from case 2.