Chronic Mechanical Circulatory Support Research Articles

Advanced Heart Failure: Therapeutic Options and Challenges in the Evolving Field of Left Ventricular Assist Devices.

Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.

Mechanical circulatory support for adults in Japan: A 10-year perspective.

Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid-term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2-year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long-term LVAD support have become important. Five important topics including hemocompatibility-related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia-Pacific region and beyond.

Incidence and risk factors of late right heart failure in chronic mechanical circulatory support.

Late right heart failure (LRHF) is a common complication during long-term left ventricular assist device (LVAD) support. We aimed to identify risk factors for LRHF after LVAD implantation. Patients undergoing primary LVAD implantation between 2006 and 2019 and surviving the perioperative period were included for this study (n = 261). Univariate Cox proportional hazards analysis was used to assess the association of clinical covariates and LRHF, stratified for device type. Variables with p < 0.10 entered the multivariable model. In a subset of patients with complete echocardiography or right catheterization data, this multivariable model was extended. Postoperative cardiopulmonary exercise test data were compared in patients with and without LRHF. Nineteen percentage of patients suffered from LRHF after a median of 12 months, of which 67% required hospitalization. A history of atrial fibrillation (AF) (HR: 2.06 [1.08-3.93], p = 0.029), a higher preoperative body mass index (BMI) (HR: 1.07 [1.01-1.13], p = 0.023), and intensive care unit (ICU) duration (HR: 1.03 [1.00-1.06], p = 0.025) were independent predictors of LHRF in the multivariable model. A significant relation between the severity of tricuspid regurgitation (TR) and LRHF (HR: 1.91 [1.13-3.21], p = 0.016) was found in patients with echocardiographic data. Patients with LRHF demonstrated a lower maximal workload and peak VO2 at 6 months postoperatively. A history of AF, BMI, and longer ICU stay may help identify patients at high risk for LRHF. Severity of TR was significantly related to LRHF in a subset of patients.

Cardiogenic shock incidence, management and prognosis in adults with congenital heart disease: Insight from the FRENSHOCK registry

Data on cardiogenic shock (CS) in adults with congenital heart disease (ACHD) are scarce. We sought to describe CS in ACHD in a nationwide CS registry. From the multicentric Frenshock registry ( n = 772 CS from 49 French centers between April and October 2016), ACHD CS were compared with non-ACHD ones. The primary outcome was defined by mortality, chronic mechanical circulatory support (MCS) or heart transplantation at 1year. Out of the 772 patients, 7 (1%) were ACHD. ACHD patients were younger (53.9 vs. 65.8-years-old), with less cardiovascular risk factor, such as hypertension (14.2 vs. 47.5%) and diabetes (14.3% vs. 36.1%), and no ischemic cardiopathy (0% vs. 61.5%). Right heart catheterization (57.1% vs. 15.4%), pacemaker (28.6 vs. 4.6%) and ICD (28.6 vs. 4.8%) were more frequently indicated in the ACHD CS management compared to non-ACHD CS, whereas temporary MCS (0 vs. 7.2%) and invasive mechanical ventilation (14.3% vs. 38.1%) were less likely used in ACHD. At 1-year of follow-up, primary outcome occurred in 85.7% ACHD and 52.2% non ACHD ( P = 0.127). Left ventricular assist device (14.3 vs. 5.4%, P = 0.3251), and heart transplantation (8.57 vs. 5.23%, P = 0.05) were more frequently used in ACHD. However, 1-year mortality in ACHD and non-ACHD patients was the same (45.4 vs. 42.9%, P = 1) ( Fig. 1 ). CS in ACHD is rare accounting for 1% of CS population. Despite a younger population with fewer cardiovascular risk factors, the prognosis remains severe.

Nephrology Considerations in the Management of Durable and Temporary Mechanical Circulatory Support.

Durable and temporary mechanical circulatory support (MCS) use is growing for a range of cardiovascular indications. Kidney dysfunction is common in people evaluated for or receiving durable or temporary MCS and portends worse outcomes. This kidney dysfunction can be due to preexisting kidney chronic kidney disease (CKD), acute kidney injury (AKI) related to acute cardiovascular disease necessitating MCS, AKI due to cardiac procedures, and acute and chronic MCS effects and complications. Durable MCS, with implantable continuous flow pumps, is used for long-term support in advanced heart failure refractory to guideline-directed medical and device therapy, either permanently or as a bridge to heart transplantation. Temporary MCS-encompassing in this review intra-aortic balloon pumps (IABP), axial flow pumps, centrifugal flow pumps, and venoarterial ECMO-is used for diverse situations: high-risk percutaneous coronary interventions (PCI), acute decompensated heart failure, cardiogenic shock, and resuscitation after cardiac arrest. The wide adoption of MCS makes it imperative to improve understanding of the effects of MCS on kidney health/function and of kidney health/function on MCS outcomes. The complex structure and functions of the kidney, and the complex health states of individuals receiving MCS, makes investigations in this area challenging, and current knowledge is limited. Fortunately, the increasing nephrology toolbox of noninvasive kidney health/function assessments may enable development and testing of individualized management strategies and therapeutics in the future. We review technology, epidemiology, pathophysiology, clinical considerations, and future directions in MCS and nephrology.

Listing criteria for heart transplantation in the Netherlands

The updated listing criteria for heart transplantation are presented on behalf of the three heart transplant centres in the Netherlands. Given the shortage of donor hearts, selection of those patients who may expect to have the greatest benefit from a scarce societal resource in terms of life expectancy and quality of life is inevitable. The indication for heart transplantation includes end-stage heart disease not remediable by more conservative measures, accompanied by severe physical limitation while on optimal medical therapy, including ICD/CRT‑D. Assessment of this condition requires cardiopulmonary stress testing, prognostic stratification and invasive haemodynamic measurements. Timely referral to a tertiary centre is essential for an optimal outcome. Chronic mechanical circulatory support is being used more and more as an alternative to heart transplantation and to bridge the progressively longer waiting time for heart transplantation and, thus, has become an important treatment option for patients with advanced heart failure.Supplementary InformationThe online version of this article (10.1007/s12471-021-01627-x) contains supplementary material, which is available to authorized users.

DESIGN AND DEVELOPMENT OF MINIATURE SLOTTED IMPELLER FOR SAI SPANDAN TOTAL ARTIFICIAL HEART FOR DESTINATION THERAPY

In recent years, the use of rotary blood pumps (RBPs) as continuous ow VADs has surged ahead, and virtually eliminated the use of pulsatile-ow or volume-displacement pumps for implantable, chronic mechanical circulatory support (MCS). Circuit Design modications like that in Saispandan has imparted pulsatility into RBP.Impeller designs are a signicant factor when designing centrifugal pumps as mechanical circulatory assist devices as smaller diameter impellers with higher rotational speeds to achieve target outputs would cause more blood component trauma compared to larger diameter impellers.Hydraulic performance and hemolysis tests in the same pump housing with different prototypes is needed. Ventricular assist parameters for efcient circulatory support would include an output of 5 L/min against 100 mmHg at speeds of 2500-3500 rpm. Vein height does not contribute signicantly to evaluation metric in most studies.

Application of an Absorbable Antimicrobial Mesh Reduces Major Driveline Infection in Chronic Mechanical Circulatory Support

Driveline infections (DLI), the main entity of VAD specific infections, in chronic mechanical circulatory support (MCS) increase with extended support times and contribute significantly to mortality and morbidity. The incidence of DLIs remains high at up to 30% at one year and often necessitate extensive surgical revisions, VAD exchange, or heart transplantation. Recently, an absorbable antimicrobial mesh impregnated with rifampin and minocycline (TYRX) was demonstrated to significantly reduce chronic implantable electric device infections. We evaluated the incidence of major DLIs in patients supported mechanically with or without the use of TYRX. Starting January 2015, 63 patients were supported by chronic MCS (HVAD: 60, HM3: 3) without TYRX use (group1); while starting December 2017, 56 patients were supported by chronic MCS (HVAD: 55, HM3: 1) with the additional use of TYRX to the driveline (group2). Operative technique and follow-up care remained unchanged. Major driveline infections were defined by the need of surgical revision, VAD exchange, heart transplantation, or life-time antibiotic treatment. Statistical significance was calculated by the log-rank test. In group 2, TYRX was tolerated in all 56 patients without any specific complication. Mean observation time was 891 days (37 to 1730) in group 1 and 285 days (40 to 679) in group 2. In group 1, 18 major DLI (28.6%) were documented at a mean of 459 days (23 to 1086) of support, and freedom of major DLI at one year was 84%. In group 2, 1 major DLI (1.8%) was detected at 291 days of support, and freedom of major DLI at one year was 96%. Comparison of the two groups reached statistical significance favoring TYRX use (p=0.045). In a single-center observation, additional wrapping of an absorbable antimicrobial mesh (TYRX) is safe, feasible, and significantly reduces the incidence of major driveline infection.

Apixaban in Chronic Mechanical Circulatory Support in Patients Non-Compliant to Vitamin-K Based Anticoagulation

Non-Compliance has been defined as an independent late risk factor for patients with chronic Mechanic Circulatory Support. Times in therapeutic range (TTR) above 70% in Vitamin K based anticoagulation (VKA) are only achieved with INR self-management and additional telephone surveillance requiring tremendous logistics and compliance.We investigated an alternative anticoagulation regime with Apixaban and Multiplate controlled platelet inhibition therapy in this sensitive cohort. Since July 2014, 48 patients with a mean age 65,6 years (36 to 82), supported by Medtronic HVAD (47) or Abbott Heartmate 3 (1), identified as non-compliant to VKA were anticoagulated by Apixaban 5mg bid and either Aspirin or Clopidogrel. Non-compliance was defined as either an inability to become trained to perform INR self-management or 3 INR values requiring intervention.Cerebrovascular events were assessed. Mean anticoagulation with Apixaban was 371 days (24 - 810), sum 17815 days. 33 patients received Clopidogrel, 14 Aspirin. Overall, 5 cerebrovascular events (10,5%) were documented. Of these, 2 were fatal hemorrhagic (4,1%) and 3 were ischemic events (6,3%), all resolving to a Modified Rankin Score of <3. One-year freedom of cerebrovascular, ischemic or hemorrhagic cerebrovascular events were 90%, 96% and 94%, respectively. Apixaban 5 mg bid and Multiplate-controlled platelet inhibition appears to be a safe and effective alternative in patients non-compliant to standard VKA in a single center observation. Larger trials to investigate Apixaban's potential to replace VKA as standard of care are needed.

Apixaban in HVAD Patients Non-Compliant to Standard Vitamin-K-Antagonism

Purpose Long-term outcome of patients with chronic mechanical circulatory support (MCS) depends significantly on the time in INR-Target-Range (ITTR) to prevent detrimental adverse events such as VAD thrombosis and cerebrovascular accidents (CVA). Despite intensified INR self-management and patient education, intraindividual variations preclude high ITTR in some, delineating a significant risk. Patients non-compliant to standard vitamin K antagonism (VKA) represent a therapeutic challenge with dismal outcomes. Postoperative transitioning to VKA by direct Xa inhibitors is well established. We present the outcome of patients non-compliant to VKA supported by Medtronic HVAD anticoagulated chronically with the direct Xa inhibitor Apixaban. Methods 22 HVAD-patients, aged 64,5 years (35-81) were anticoagulated by Apixaban 10 mg in combination with either 100 mg Aspirin (n=10) or 75 mg Clopidogrel (n=12) daily, controlled by multiplate testing. Non-compliance was defined as inability to apply the INR self-management reliably after 3 or more extensive trainings or the documentation of 3 or more low INR, requiring therapeutic intervention. LDH was recorded serially to detect early VAD thrombosis. Results Apixaban therapy was begun after a median of 25,5 days (3 - 1533) of standard therapy. Observational time on Apixaban ranged from 21 - 518 days (mean 263 ± 122) summing up to 5786 days. Mean time on device was 408 ± 296 days (45 - 1554). All patients tolerated the Apixaban therapy well with no compliance issues. Clinically, no signs of pump thrombosis were detected in this cohort. Plasma LDH demonstrated regular values with a mean of 210 ± 42,2U/l. Two fatal intracranial hemorrhages 127 and 513 days on Apixaban occurred, respectively, in one case according to an intracrainial aneurysmal bleeding.Overall survival in this cohort is 90,9%. Conclusion In the challenging cohort of HVAD patients non-compliant to standard VKA therapy Apixaban appears to be a safe, well tolerated and efficient therapeutic alternative. In our single center observation of 22 HVAD patients anticoagulated by Apixaban no pump thrombosis was detected with regular LDH parameter. Two fatal intracrainial bleedings occurred, in one case after a predisposing condition preoperatively.

The Achilles' heel of left ventricular assist device therapy: right ventricle.

Many patients suffer from either persistent right ventricular failure (RVF) at the time of left ventricular assist device (LVAD) or have ongoing symptoms consistent with RVF during chronic mechanical circulatory support. The lack of long-term right ventricular assist devices (RVADs) has limited the impact that mechanical circulatory support can provide to patients with biventricular failure. We aim to review the entire spectrum of RVF in patients receiving LVADs and reflect on why this entity remains the Achilles' heel of LVAD therapy. In the early postoperative period, LVAD implantation reduces right ventricle (RV) afterload, but RV dysfunction may be exacerbated secondary to increased venous return. With prolonged therapy, the decreased RV afterload leads to improved RV contractile function. Bayesian statistical models outperform previously published preoperative risk scores by considering inter-relationships and conditional probabilities amongst independent variables. Various echocardiographic parameters and the pulmonary artery pulsatility index have shown promise in predicting post-LVAD RVF. Recent publications have delineated the emergence of 'delayed' RVF. Several devices are currently being investigated for use as RVADs. Post-LVAD RVF depends on the RV's ability to adapt to acute hemodynamic changes imposed by the LVAD. Management options are limited due to the lack of an easily implantable, chronic-use RVAD.

Cardiac Rotational Mechanics As a Predictor of Myocardial Recovery in Heart Failure Patients Undergoing Chronic Mechanical Circulatory Support: A Pilot Study.

Impaired qualitative and quantitative left ventricular (LV) rotational mechanics predict cardiac remodeling progression and prognosis after myocardial infarction. We investigated whether cardiac rotational mechanics can predict cardiac recovery in chronic advanced cardiomyopathy patients. Sixty-three patients with advanced and chronic dilated cardiomyopathy undergoing implantation of LV assist device (LVAD) were prospectively investigated using speckle tracking echocardiography. Acute heart failure patients were prospectively excluded. We evaluated LV rotational mechanics (apical and basal LV twist, LV torsion) and deformational mechanics (circumferential and longitudinal strain) before LVAD implantation. Cardiac recovery post-LVAD implantation was defined as (1) final resulting LV ejection fraction ≥40%, (2) relative LV ejection fraction increase ≥50%, (iii) relative LV end-systolic volume decrease ≥50% (all 3 required). Twelve patients fulfilled the criteria for cardiac recovery (Rec Group). The Rec Group had significantly less impaired pre-LVAD peak LV torsion compared with the Non-Rec Group. Notably, both groups had similarly reduced pre-LVAD LV ejection fraction. By receiver operating characteristic curve analysis, pre-LVAD peak LV torsion of 0.35 degrees/cm had a 92% sensitivity and a 73% specificity in predicting cardiac recovery. Peak LV torsion before LVAD implantation was found to be an independent predictor of cardiac recovery after LVAD implantation (odds ratio, 0.65 per 0.1 degrees/cm [0.49-0.87]; P=0.014). LV rotational mechanics seem to be useful in selecting patients prone to cardiac recovery after mechanical unloading induced by LVADs. Future studies should investigate the utility of these markers in predicting durable cardiac recovery after the explantation of the cardiac assist device.

Initial in vitro testing of a paediatric continuous-flow total artificial heart.

Mechanical circulatory support has become standard therapy for adult patients with end-stage heart failure; however, in paediatric patients with congenital heart disease, the options for chronic mechanical circulatory support are limited to paracorporeal devices or off-label use of devices intended for implantation in adults. Congenital heart disease and cardiomyopathy often involve both the left and right ventricles; in such cases, heart transplantation, a biventricular assist device or a total artificial heart is needed to adequately sustain both pulmonary and systemic circulations. We aimed to evaluate the in vitro performance of the initial prototype of our paediatric continuous-flow total artificial heart. The paediatric continuous-flow total artificial heart pump was downsized from the adult continuous-flow total artificial heart configuration by a scale factor of 0.70 (1/3 of total volume) to enable implantation in infants. System performance of this prototype was evaluated using the continuous-flow total artificial heart mock loop set to mimic paediatric circulation. We generated maps of pump performance and atrial pressure differences over a wide range of systemic vascular resistance/pulmonary vascular resistance and pump speeds. Performance data indicated left pump flow range of 0.4-4.7 l/min at 100 mmHg delta pressure. The left/right atrial pressure difference was maintained within ±5 mmHg with systemic vascular resistance/pulmonary vascular resistance ratios between 1.4 and 35, with/without pump speed modulation, verifying expected passive self-regulation of atrial pressure balance. The paediatric continuous-flow total artificial heart prototype met design requirements for self-regulation and performance; in vivo pump performance studies are ongoing.

Clinical and histopathological effects of heart failure drug therapy in advanced heart failure patients on chronic mechanical circulatory support.

Adjuvant heart failure (HF) drug therapy in patients undergoing chronic mechanical circulatory support (MCS) is often used in conjunction with a continuous-flow left ventricular assist device (LVAD), but its potential impact is not well defined. The objective of the present study was to examine the effects of conventional HF drug therapy on myocardial structure and function, peripheral organ function and the incidence of adverse events in the setting of MCS. Patients with chronic HF requiring LVAD support were prospectively enrolled. Paired myocardial tissue samples were obtained prior to LVAD implantation and at transplantation for histopathology. The Meds group comprised patients treated with neurohormonal blocking therapy (concurrent beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and aldosterone antagonist), and the No Meds group comprised patients on none of these. Both the Meds (n = 37) and No Meds (n = 44) groups experienced significant improvements in cardiac structure and function over the 6 months following LVAD implantation. The degree of improvement was greater in the Meds group, including after adjustment for baseline differences. There were no differences between the two groups in arrhythmias, end-organ injury, or neurological events. In patients with high baseline pre-LVAD myocardial fibrosis, treatment with HF drug therapy was associated with a reduction in fibrosis. Clinical and histopathological evidence showed that adjuvant HF drug therapy was associated with additional favourable effects on the structure and function of the unloaded myocardium that extended beyond the beneficial effects attributed to LVAD-induced unloading alone. Adjuvant HF drug therapy did not influence the incidence of major post-LVAD adverse events during the follow-up period.

(679) - Greater Omentum Plasty for the Treatment of Deep Driveline Infection in Chronic Mechanical Circulatory Support

(679) - Greater Omentum Plasty for the Treatment of Deep Driveline Infection in Chronic Mechanical Circulatory Support

Renal dysfunction and chronic mechanical circulatory support: from patient selection to long-term management and prognosis.

The purpose of this review is to describe the effects of mechanical circulatory support (MCS) on changes in kidney function and their relationship with mortality, with an additional focus on the evaluation and management of both preimplant and post-MCS renal dysfunction. Renal dysfunction is highly prevalent in patients referred for MCS and is associated with significantly increased mortality and postoperative acute kidney injury. Most patients, including those with renal dysfunction, experience marked early improvement in renal function with MCS, likely secondary to correction of the cardiogenic shock, volume overload, and neurohormonal activation characteristic of advanced heart failure. Currently, there are no diagnostic tests to definitively distinguish reversible forms of renal dysfunction likely to improve with MCS from irreversible renal dysfunction. Furthermore, the characteristic improvements in renal function observed in the early months of MCS are often transient, with subsequent recurrence of renal dysfunction with longer durations of support. Venous congestion, right ventricular dysfunction, and reduced pulsatility are potential mechanisms involved in resurgence of renal dysfunction following MCS. With the exponential growth of MCS, research endeavors to both improve understanding of the mechanisms behind observed changes in renal function and elucidate the device-related effects on the kidney are imperative.

Exercise physiology in chronic mechanical circulatory support patients: vascular function and beyond.

The majority of patients currently implanted with left ventricular assist devices have the expectation of support for more than 2 years. As a result, survival alone is no longer a sufficient distinctive for this technology, and there have been many studies within the last few years examining functional capacity and exercise outcomes. Despite strong evidence for functional class improvements and increases in simple measures of walking distance, there remains incomplete normalization of exercise capacity, even in the presence of markedly improved resting hemodynamics. Reasons for this remain unclear. Despite current pumps being run at a fixed speed, it is widely recognized that pump outputs significantly increase with exercise. The mechanism of this increase involves the interaction between preload, afterload, and the intrinsic pump function curves. The role of the residual heart function is also important in determining total cardiac output, as well as whether the aortic valve opens with exercise. Interactions with the vasculature, with skeletal muscle blood flow and the state of the autonomic nervous system are also likely to be important contributors to exercise performance. Further studies examining optimization of pump function with active pump speed modulation and options for optimization of the overall patient condition are likely to be needed to allow left ventricular assist devices to be used with the hope of full functional physiological recovery.

(537) - The Impact of Baseline Renal Dysfunction on Patient Outcomes after Implantation of Chronic Mechanical Circulatory Support Devices

(537) - The Impact of Baseline Renal Dysfunction on Patient Outcomes after Implantation of Chronic Mechanical Circulatory Support Devices

Effect of Long-Term Circulatory Support on Arterial Wall: Comparison of Histological Findings in Pulsatile and Continuous Flow Blood Pump Recipients

Introduction: Continuous flow (CF) ventricular assist devices (VAD) are an established option for treatment of end-stage heart failure. However, the impact of long-term continuous flow with lack of peripheral arterial wall motions on blood pressure regulation and end-organ arterial wall sclerosis, especially in the case of long-term support (over 3 years), remains unclear. Methods: Samples of arterial wall (liver, kidney, coronary and cerebral arteries) from a total of 27 VAD recipients supported for >180 days between 2000 and 2010 were examined for perivascular infiltrate, intravascular infiltrate, wall thickness, thrombosis, endothelial cell swelling, vessel wall necrosis and perivascular fibrosis. In nine patients pulsatile devices (group P), and in 16 patients CF devices had been inserted (group CF). The pathologist was blinded to the group distribution. Demographic, pharmacological and clinical data were retrospectively analyzed before surgery and during the follow -up period of up to 24 months. Results: Median duration of support was in group P 467 days (range 235-1588 days) and in group CF 263 days (range 182-942 days). There were no differences in demographic and clinical data before and after surgery. During follow-up amiodaron was more often used in the CF group than the P group (61% vs. 10%, p=0.009). Throughout the follow-up period mean arterial pressure did not differ between recipients of the two pump types; nor did systolic and diastolic pressure, except at the time point of 2 weeks after VAD implantation (systolic blood pressure was higher (p=0.05) and diastolic lower (p=0.03) in group P). Histological studies did not recognize any relevant differences in arterial wall characteristics between the two groups. Conclusion: Chronic mechanical circulatory support for up to 4 years with CF devices does not adversely influence arterial wall properties of the end-organ vasculature.

186 Long Term Mechanical Circulatory Support: What Are the Final Options?

Despite advances in medical therapy, thousands of patients (pts) with end-stage diseases die each year awaiting a suitable donor organ. In cardiac transplantation, pts can be bridged using chronic mechanical circulatory support (MCS) until a suitable cardiac allograft becomes available. Contemporary MCS devices support systemic circulation with a continuous flow (CF) mechanism that generates non-physiological, non-pulsatile blood flow to vital organs. We present an unconventional case of orthotopic liver transplantation (OLT) from a deceased donor with end-stage heart failure who had been managed using a non-pulsatile MCS device.