Advances in mechanical circulatory support: Year in review

Abstract

Mechanical circulatory support (MCS) in cardiac surgery is approaching its 50th anniversary. In the early 1960s, DeBakey developed the first ventricular assist device (VAD) and, in 1966, reported its first successful use for bridge to recovery in post-cardiotomy syndrome in a 37-year-old woman. VAD utilization is among the most effective options for treatment of acute or chronic end-stage heart failure. In Europe, more MCS systems are implanted than hearts transplanted, and in the near future this will also be the case in North America. However, despite enormous progress in the field in the past 50 years, there remain many obstacles yet to be overcome. Continuous-flow pumps, introduced in the past 12 years, represent a major advance, as the associated complication rate is significantly lower than with earlier pulsatile systems. The key developments of the year 2010 are the increased numbers of studies showing the low complication rate and excellent durability of continuous-flow pumps, developments resulting from technology related to mechanical bearings and magnetic or hydrodynamic levitation. Both the improved durability and low complication rate profile have now allowed a shift from “saving the life” of patients with severe cardiogenic shock and NYHA Class IV status to “improving the quality of life” of patients with NYHA Class III or IV. Another key advancement is the smaller pump size, which enables simplified surgical implantation through sternotomy or left thoracotomy and, in some cases, without cardiopulmonary bypass. This results in a lower risk of peri-operative complications and thus allows utilization of such therapy in older or sicker patients, which was not possible with earlier types of devices. Because in some selected groups of patients with MCS the morbidity and mortality rates are approaching those of the patients who receive the “gold standard” of care—heart