Duration Of Mechanical Circulatory Support Research Articles

Postcardiotomy ECMO Support after High-risk Operations in Adult Congenital Heart Disease.

Cardiac operations in high-risk adult congenital heart disease (ACHD) patients may require mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pump (IABP), to allow the cardiopulmonary system to recover. We reviewed records for all ACHD patients who required MCS following cardiotomy at our institution from 1/2001 to 12/2013. During the study period, 2264 (mean age 39.1 years, females ∼54.1%) operations were performed in ACHD patients of whom 24 (1.1%) required postoperative MCS (14 males; median age 41 years, range 22-75). Preoperatively the 24 patients had a mean systemic ventricular ejection fraction of 47% (range 10-66%); 72% of these patients were in NYHA class III/IV heart failure. The common underlying diagnoses included pulmonary atresia with intact ventricular septum (20%), tetralogy of Fallot (16%), Ebstein anomaly (12%), cc-TGA (12%), septal defects (12%), and others (28%). Operations performed were valvular operations with/without maze (58.2%), Fontan conversion (21%), coronary bypass grafting with valvular operations (12.5%), and heart transplant (8.3%). Indications for MCS were left-sided (systemic) heart failure (32%), right-sided (subpulmonary) heart failure (24%), biventricular heart failure (36%), persistent arrhythmia (4%), and hypoxemia (4%). Forty-two percent were placed on ECMO only; in the second group, IABP was attempted and subsequently followed by ECMO initiation. The mean duration of MCS was 8.4 days (range 0.8-35.4). Common morbidities included coagulopathy (60%), renal failure (56%), and arrhythmia (48%). Overall, 46% of patients survived to hospital discharge. Deaths were due to either multi organ failure or the underlying cardiac disease; sepsis was the primary cause of death in one patient. Median follow-up for survivors was 41 months (maximum 106 months). NYHA functional class was I/II in all 8 late survivors. Following complex operations in high-risk ACHD patients, MCS may be required. Despite significant morbidity, nearly half of patients survive to hospital discharge.

Mechanical Circulatory Support as Bridge to Transplantation for the Failing Single Ventricle

Circulatory failure necessitating cardiac transplantation will ultimately develop in many patients with functional single-ventricle physiology. Interest in the use of mechanical circulatory support (MCS) in this population is growing. This was a retrospective case series of patients with functional single-ventricle physiology who underwent MCS with a ventricular assist device or a totalartificial heart as a bridge to cardiac transplantation between January 2006 and December 2014. Baseline demographics, intraoperative data, postoperative complications, and outcome data were collected from the medical record. MCS was used in 5 patients: HeartWare ventricular assist device (HeartWare International, Framingham, MA) in 1 patient, SynCardia total artificial heart (SynCardia Systems, Tucson, AZ) in 1, Thoratec Paracorporeal ventricular assist device (Thoratec Corp, Pleasanton, CA) in 1, and the Berlin Heart EXCOR (Berlin Heart Inc, The Woodlands, TX) in 2. The mean age at MCS was 12 ± 8 years. There were 2 early deaths at 12 and 28 days after MCS: 1 patient died of multiorgan system failure and 1 of neurologic injury. Overall, neurologic complications occurred in 3 patients (60%), and 1 patient (20%) required renal replacement therapy. Three patients (60%) underwent successful cardiac transplantation. The median time on the waiting list was 59 days (interquartile range, 18 to 126 days), and the median duration of MCS was 60 days (interquartile range, 28 to 93 days). At the time of transplant, all 3 patients were ambulatory, without the need for mechanical ventilation, and end-organ dysfunction had resolved. The 3 patients who received transplants were discharged from the hospital and were alive at an average follow-up of 9 ± 14 months. MCS can be successfully used as a bridge to transplantation in patients with a failing single-ventricle circulation. Use of MCS can allow for resolution of end-organ dysfunction and rehabilitation, leading to improved outcomes in this difficult population.

Evolution and Impact of Ventricular Assist Device Program on Children Awaiting Heart Transplantation

We sought to evaluate the impact of the evolution of a pediatric mechanical circulatory support (MCS) program on outcomes of children listed for heart transplantation at our institution. All patients listed for isolated heart transplantation from 1995 to 2013 were included. The use of MCS while on the wait-list was recorded. Wait-list and posttransplant outcomes were compared before and after 2005, which was when we became capable of providing long-term MCS without size limitation. In total, 259 patients were listed for transplant and 201 (78%) reached transplant. The use of MCS was significantly increased between the eras (13% and 37%, p = 0.0001). Wait-list mortality was significantly decreased (25% and 11%, p = 0.0006). Among transplant recipients, the proportion of patients who underwent MCS was significantly increased (13% and 37%, p = 0.0002). Of these MCS patients, the use of long-term devices was significantly increased (50% and 98%, p = 0.0004). Median duration of MCS was significantly increased (12 and 78 days, p = 0.004). Kaplan-Meier estimates showed a trend (p = 0.08) toward improved survival after bridge-to-transplant both at 1 year (70% in the early era and 88% in the late era) and at 5 years (60% and 78%, respectively). Outcomes of pediatric heart transplantation have significantly improved over the last 2 decades. We believe such improvement is, at least in part, attributable to maturation of MCS strategy, characterized by avoiding the use of temporary devices such as extracorporeal membrane oxygenation as a bridge-to-transplant and a more aggressive use of long-term devices.

Human Leukocyte Antigen Sensitization in Pediatric Patients Exposed to Mechanical Circulatory Support

Human leukocyte antigen (HLA) sensitization of pediatric heart recipients increases their risk of rejection and graft loss. As more children are placed on mechanical circulatory support (MCS) as a bridge to transplant, the risk factors for development of sensitization warrant further study. A single-center retrospective review of 36 children who received MCS identified 22 patients supported with either extracorporeal membrane oxygenation (ECMO) (n = 15) or ECMO-ventricular assist device (VAD) (n = 7) with paired (pre-MCS/post-MCS) panel reactive antibodies (PRA) or only negative post-MCS PRAs. Four patients (18%) became sensitized post-MCS (one ECMO-only patient, three ECMO-VAD patients). No difference was found between sensitized and nonsensitized patients in terms of congenital heart disease versus primary cardiomyopathy (p = 0.096), duration of MCS (38 days vs. 14 days, p = 0.233), or volume of blood product transfusions (358.6 ml/kg vs. 612.7 ml/kg, p = not significant). By multivariable analysis, the association of sensitization with older age at MCS (p = 0.076) and history of homograft (p = 0.064) approached significance. Pediatric patients supported with MCS are at low risk of developing HLA sensitization. Diagnosis, MCS duration, and volume of transfused blood products do not appear to be associated with HLA sensitization, but there is a suggestion of an association with older age at MCS and history of a homograft.

Abstract 18745: Outcomes of Mechanical Circulatory Support for Patients With Functionally Single-Ventricle Physiology at Different Stages of Surgical Palliation

Introduction: Mechanical circulatory support (MCS) for functionally single ventricle (SV) physiology poses significant challenges. We sought to analyze the results of MCS at 4 different stages of the surgical palliation process. Methods: From 2003 to 2013, 86 SV patients required MCS: Group 1, before any surgical palliation (n=13, 15%), Group 2, between stage I and II (n=59, 69%), Group 3, between stage II and Fontan (n=10, 12%), Group 4, after Fontan (n=4, 5%). Indications for MCS included failure to wean from cardiopulmonary bypass in 6 (7%) patients, circulatory failure in 7 (8%), respiratory failure in 9 (10%), cardiopulmonary failure in 4 (5%), and cardiac arrest in 58 (67%). Kaplan-Meier analysis was used to compare freedom from death and freedom from failure to wean between groups. Cox analysis was used to determine risk factors. Results: The median MCS duration was 3 days (IQR, 1-6). Of 86 patients, 58 (67%) were successfully weaned: 32 (37%) patients recovered, 8 (9%) were transplanted, 12 (14%) had operation/reoperation, and 1 (1%) had conversion to a different form of MCS. Fifty-two (60%) patients had complications including bleeding in 20, thromboembolism in 9, sepsis in 12, neurologic injury in 6, and multi-organ failure in 5. Thirteen patients required a second run of MCS. Freedom from death at 6 months after MCS initiation was comparable between the groups (Group 1, 23%, Group 2, 33%, Group 3, 15%, Group 4, 50%, p=0.66; Figure 1). Failure to wean from MCS was also comparable among the groups (p=0.46). Cox analysis revealed MCS-related complications as a risk factor for death (p=0.006) and longer duration of arrest as a risk factor for inability to wean from ECMO (p=0.036). The timing of MCS was not a risk factor for poor outcomes. Conclusions: Two thirds of SV patients who required MCS were rescued, although subsequent survival is generally poor across all stages of palliation. Given the poor outcomes in this cohort, consideration of alternative strategies is warranted.

First serial in vivo results of mechanical circulatory support in children with a new diagonal pump

Mechanical circulatory support (MCS) is a rescue therapy for infants and children suffering from severe cardiorespiratory failure with specific system-related complications like bleeding, thromboembolism and device failure. Novel circuit components for temporary MCS with improved haemodynamic properties may improve patients' outcome and reduce system-related morbidities. The Deltastream DP3 (Medos Medizintechnik AG, Stolberg, Germany) is a newly designed rotational pump with a diagonally streamed impeller that can be used in children of all ages (priming volume 16 ml, flow 0-8 l/min). The aim of this study was to analyse the feasibility and safety of the DP3 pump system in children. We retrospectively investigated a consecutive series of 16 children [median age 0.9 months (0.1-55 months), median weight 3.2 kg (2.5-14 kg)]. The DP3 circuit was used 22 times in these children for different indications: (I) extracorporeal life support (ECLS) in post-cardiotomy heart failure (n = 11), (II) ECLS in cardiopulmonary resuscitation (CPR) (n = 7) and (III) extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS) (n = 4). Median duration of MCS was 4 days (0-18 days), 12 patients (75%) were weaned successfully from MCS, 4 of these children (25%) died after weaning, with a median survival time of 15 days (6-28 days). Overall survival rate was 50% and all 8 survivors were discharged home without neurological injury. There was no case of severe bleeding, thromboembolic complications or device failure. Mean lactate dehydrogenase (LDH) before MCS was 700 (±384) U/l, and increased to a maximum of 2279 (±2635) U/l during MCS (P = 0.04). Baseline D-dimer values were 3.4 (±3.0) mg/l and rose significantly to 19.5 (±11.5) mg/l during MCS (P < 0.001). The mean of the highest plasma-free haemoglobin during MCS was 21.0 (±42.9) mg/dl. The increase in plasma-free haemoglobin correlated moderately with the duration of MCS (Pearson's r: 0.78). The use of the Deltastream DP3 seems to be safe and effective for MCS in children and may show a low degree of haemolysis. We observed no system-related complications and an overall good outcome in this demanding patient cohort.

Heart transplantation after short-term mechanical circulatory support

IntroductionShort-term ventricular assist device (VAD) implantation is a life-saving procedure in patients with refractory cardiogenic shock. The present paper provides our experience with patients we were able to bridge from this critical condition directly to heart transplantation. MethodOur group comprises 11 patients implanted a Levitronix CentriMag short-term ventricular assist device from April 2009 to October 2012 as a bridge to heart transplantation. Six (55%) patients received a biventricular assist device while five (45%) had a left-ventricular assist device implanted. The mean age of patients was 41.2 years (20–63 years). Our group of patients included eight men (73%). The underlying diagnoses included dilated cardiomyopathy (5 patients), coronary heart disease (4 patients), infective endocarditis, and primary graft failure (1 patient each). Prior to implantation, all patients received high doses of inotropes, and eight (73%) patients had mechanical ventilatory support. Six (55%) patients showed laboratory signs of liver and kidney failure, and metabolic acidosis. ResultsThe mean time from VAD implantation to putting the patient on the urgent waiting list for heart transplantation was 7.6 days (1–54 days) depending on organ function recovery. The mean duration of mechanical circulatory support was 26.7 days (8–72 days). The mean time from inclusion into the waiting list to transplantation was 19.1 days (4–52 days). One-month, six-months and one-year survivals post-transplant were 91%, 82%, and 73%, respectively. ConclusionImplantation of the CentriMag short-term ventricular assist device in patients with refractory cardiogenic shock and otherwise grim prognosis markedly increases their chances for survival. Given the relatively short waiting time in the Czech Republic, the CentriMag ventricular assist device can thus serve as a direct bridge to heart transplantation.

Comprehensive care for mechanical circulatory support: a new frontier for synergy with palliative care.

Heart Failure (HF) is a chronic and progressive illness and is a leading cause of death in the United States. Patients with end-stage HF have limited therapeutic options and thus mechanical circulatory support (MCS) is increasingly being used to treat patients with end-stage disease. Between June 2006 and June 2010, 2680 adults in the United States received a Food and Drug Administration–approved durable MCS device as treatment for end-stage HF.1 Roughly 82% of patients receiving MCS were either listed for transplant at time of implant (bridge to transplant, BTT) or had at least a moderate probability of being listed for transplant at some point during MCS (bridge to candidacy), whereas 11% were implanted as destination therapy (DT). Currently, more than 98% of patients implanted with a durable MCS device receive a continuous-flow left ventricular assist device.1 The duration of MCS and survival is influenced by a number of factors, including timing of implant, strategy of support at time of implant, age of patient, and medical comorbidities. Within the INTERMACS [Interagency Registry for Mechanically Assisted Circulatory Support] registry, 87% of BTT patients have been transplanted or are still alive on MCS at 12 months compared with 67% of DT patients. By stratifying by type of device to account for the shift to continuous flow pumps that began in 2008, 12- and 24-month actuarial survival for all patients receiving a primary continuous-flow left ventricular assist device as BTT is 83% and 75%, respectively, whereas 12-month actuarial survival for DT patients is 74%. Outcome data on patients supported by continuous-flow MCS past 2 years are limited. The combination of the increasing number of patients reaching the end stages of HF, the stable but inadequate number of available donor organs, and the continued improvements in MCS technology predicts that an increasing number …

Thioredoxin, adiponectin and clinical course of acute fulminant myocarditis

BackgroundIn an animal model of viral myocarditis, plasma levels of thioredoxin and adiponectin have been reported to be associated with the severity of inflammation and recovery of ventricular dysfunction, respectively....

Impact of Renal Function Before Mechanical Circulatory Support on Posttransplant Renal Outcomes

Renal dysfunction is common before mechanical circulatory support (MCS). Mechanical circulatory support frequently improves renal function, but the impact of pre-MCS renal dysfunction on renal function after cardiac transplantation (CTX) is unknown. Patients with MCS from January 1995 until April 2008 at a single center were included if their MCS duration was at least 60 days and they underwent successful CTX. Patients were followed for 1 year after CTX. A total of 116 patients were included in the study. Mechanical circulatory support was biventricular assist device in 28% and left ventricular assist device in 72% (continuous flow left ventricular assist device, 14%). Mean duration of MCS was 124 days. Patients were grouped according to tertiles of pre-MCS creatinine clearance (CrCl): group 1, CrCl less than 45 mL/min; group 2, CrCl between 45 and 65 mL/min inclusive; and group 3, CrCl more than 65 mL/min. Group 3 had the best renal outcomes both after MCS and 1 year after CTX. Regardless of group, patients who had a CrCl of at least 60 mL/min before CTX had similar 1-year posttransplant CrCl (55 versus 53 versus 56 mL/min for groups 1 through 3, respectively; not significantly different). However, the ability to achieve this level of renal function after MCS was less likely in those with the worst renal function before the initiation of MCS (53% versus 74% versus 90% for groups 1 through 3, respectively; p=0.001). The use of MCS leads to improvements in renal function in patients after MCS. However, the renal outcomes after CTX seem to be more dependent on the level of renal function achieved during MCS than on the level of renal function before MCS.

Bridge to transplant experience: Factors influencing survival to and after cardiac transplant

Balancing longer duration of mechanical circulatory support while awaiting functional recovery against the increased risk of adverse events with each day on support is difficult. Therefore, we investigated the complex interplay of duration of mechanical circulatory support and patient and device factors affecting survival on support, as well as survival after transplantation. From December 21, 1991, to July 1, 2006, mechanical circulatory support was used in 375 patients as a bridge to transplantation, with 262 surviving to transplant. Implantable pulsatile devices were used in 321 patients, continuous flow was used in 11 patients, a total artificial heart was used in 5 patients, external pulsatile devices were used in 34 patients, and extracorporeal membrane oxygenation was used in 68 patients. Two time-related models were developed: (1) a competing-risks multivariable model of death on mechanical circulatory support, with modulated renewal for each sequential support mode; and (2) a model of death after transplant in which patient factors and duration of mechanical circulatory support were investigated as risk factors. Survival after initiating mechanical circulatory support, irrespective of transplantation, was 86% at 30 days, 55% at 5 years, and 41% at 10 years; survival was 94%, 74%, and 58% at the same time intervals, respectively, after transplantation in those surviving the procedure. Risk factors for death included longer, but not shorter, duration of mechanical circulatory support, use of multiple devices, global sensitization, and poor renal function. Initiating mechanical circulatory support early with a single definitive device may improve survival to and after cardiac transplantation. Early transplant, which avoids infection, sensitization, and neurologic complications, may improve bridge and transplant survival.

81: Timing of Transplant Following Mechanical Circulatory Support in 375 Patients: Lessons from a Single Center Experience

Determining optimal timing of transplantation (Tx) for pts bridged on mechanical circulatory support (MCS) is difficult. Previous reports have shown early Tx (< 30 days) is thought to increase mortality, however, the benefit of awaiting full functional recovery must be counterbalanced with risk of adverse events that increase with each day on MCS. Our purpose was to investigate the complex relationship of duration of MCS and pt and device factors impacting survival after Tx.

Role of ventricular assist devices in the German heart allocation system

The Eurotransplant (ET) allocation algorithm, newly implemented in 2000, gives priority for heart transplantation (HTx) to patients with high urgency (HU) status, but now this status is rescinded upon ventricular assist device (VAD) implantation and only regained if severe complications occur during mechanical circulatory support (MCS). We studied the effects of this change on the patients in our institute who were waiting for HTx with MCS. The median duration of MCS until HTx in adult patients gradually increased from 3.1 months in 1994, reaching a peak of 16.7 months in 2000, and then gradually decreased to 6.0 months in 2003. Among the patients with VAD implantation as a bridge to HTx, two patients were on MCS for more than 1 year (the longest duration of MCS being 1.6 years) at the end of 1999, and this figure increased to nine patients and a maximum MCS duration of 3.7 years at the end of 2003. These data imply that the patients in whom a complication occurred in the early phase of MCS and who had overcome this complication underwent HTx early with HU status, and those who were stable during MCS waited a long time for HTx. Furthermore, the number of patients in the latter group is increasing. The new allocation algorithm imposes on patients with MCS waiting for HTx who are relatively young and free from complications and serious coexisting disease, very long-term MCS without an end to VAD bridging, which is almost equivalent to destination therapy.

Relationship between bridging with ventricular assist device on rejection after heart transplantation

Background Ventricular assist devices (VADs) are commonly used to bridge patients to heart transplantation. Recipients of VADs may develop anti-human histocompatibility leukocyte antigen antibodies, as reflected by elevated panel-reactive antibodies (PRA). The purpose of this study was to evaluate the relationship between bridging with VAD before heart transplantation and development of cellular rejection, humoral rejection, and allograft vasculopathy after transplantation. Methods Data on all patients who underwent cardiac transplantation between July 1994 and February 2001 at Rush Presbyterian St Luke’s Medical Center were retrospectively reviewed. Data collected included sex, age, etiology of cardiomyopathy, percentage panel reactive antibodies (by cytotoxic method), type and duration of mechanical circulatory support, transfusion history, rejection history (both cellular and humoral) after cardiac transplantation, and development of allograft vasculopathy. Cellular rejection was treated when International Society of Heart and Lung and Transplantation Grade 2 or greater in the first 12 months after transplant and Grade 3 or greater after 12 months and treated with intensification of immunosuppression. Humoral rejection was defined clinically as allograft dysfunction by echocardiography without evidence of cellular rejection on endomyocardial biopsy or allograft vasculopathy. Allograft vasculopathy was defined by presence of any degree of luminal narrowing or pruning of distal vessels by coronary arteriography. Statistical analyses were performed by chi-square test, Fisher’s exact test, and Wilcoxon rank sum test, as appropriate. Results Ninety-eight patients underwent cardiac transplantation during the study period (87 men, mean age 49 years, 46 ischemic etiology). Of these, 48 were bridged with HeartMate VAD (20 patients received vented electric device, 28 received pneumatic device). Nineteen percent of VAD patients had a peak pretransplant PRA ≥10% vs 2% of patients without VAD ( p = 0.014). PRA ≥10%, use of VAD, or duration of VAD support did not predict development of humoral rejection. Use of VAD did not predict development of cellular rejection or allograft vasculopathy. VAD use was not associated with sudden death after heart transplantation. In the entire group of 98 patients, neither humoral nor cellular rejection predicted development of allograft vasculopathy. Longer ischemic time correlated with increased cellular rejection and humoral rejection after transplantation ( p = 0.01). Conclusions Some patients bridged to cardiac transplantation with VADs have increased PRA before heart transplantation, but this does not appear to translate into increased risk of either humoral or cellular rejection after transplantation or development of allograft vasculopathy as detected by coronary angiography.

Mechanical circulatory support for the treatment of children with acute fulminant myocarditis

Background: Viral myocarditis may follow a rapidly progressive and fatal course in children. Mechanical circulatory support may be a life-saving measure by allowing an interval for return of native ventricular function in the majority of these patients or by providing a bridge to transplantation in the remainder. Methods: A retrospective chart review of 15 children with viral myocarditis supported with extracorporeal membrane oxygenation (12 patients) or ventricular assist devices (3 patients) was performed. Results: All patients had histories and clinical findings consistent with acute myocarditis. The median age was 4.6 years (range 1 day–13.6 years) with a median duration of mechanical circulatory support of 140 hours (range 48-400 hours). Myocardial biopsy tissue demonstrated inflammatory infiltrates or necrosis, or both, in 8 (67%) of the 12 patients who had biopsies. Overall survival was 12 (80%) of 15 patients, with 10 (83%) survivors of extracorporeal membrane oxygenation and 2 (67%) survivors of ventricular assist device support. Nine (60%) of the 15 patients were weaned from support, with 7 (78%) survivors; the remaining 6 patients were successfully bridged to transplantation, with 5 (83%) survivors. All survivors not undergoing transplantation are currently alive with normal ventricular function after a median follow-up of 1.1 years (range 0.9-5.3 years). Conclusion: Eighty-percent of the children who required mechanical circulatory support for acute myocarditis survived in this series. Recovery of native ventricular function to allow weaning from support can be anticipated in many of these patients with excellent prospects for eventual recovery of full myocardial function.

EVALUATION OF THE STRESS ON AUTONOMIC NERVOUS SYSTEM OF PATIENTS DURING MECHANICAL CIRCULATORY SUPPORT

Background: The power density values of high frequency (0.15 to 0.4 Hz) and low frequency (0.04 to 0.15 Hz) components of systemic arterial pressure (SAP) signals have been regarded as the function of autonomic nervous system(ANS). In this study, the power spectral analysis (PSA) of SAP was adopted for evaluation of the stress on ANS of patients during mechanical circulatory support. Methods: SAP signals were acquired every 2 hours at 100 Hz for 6 minitutes in patients during mechanical circulatory support (MCS). PSA was carried out, and trends of changes in the spectral components of SAP were observed in patients with MCS (IABP and/or PCPS; n=13) and without the support (n=10). Results: The normalized power spectral component in low frequency (LFAnorm) was depressed initially in all patients. The value increased gradually in all patients except 4 with MCS. Sustained low values in LFAnorm in the 4 patients were related to prolonged MCS, and 3 patients among them were expired consequently. On the contrary, the duration of MCS in 3 patients showing no LFAnorm depression in weaning from MCS was significantly shorter than that of patients weaned from MCS with LFAnorm depression. Conclusions: Depressed LFAnorm ofSAP signals represented marked stress on ANS and prolongation of the depression was related to poor outcome of patients. The depression in weaning from MCS also indicated the stress on ANS during the process. PSA of SAP offers a reasonable tool for evaluation of the stress on ANS and prediction of the prognosis of patients with circulatory assist devices.

Mechanical circulatory support as a bridge to transplantation

From December 1985 through April 1988, 11 patients (three female and eight males), 33.1 +/- 3.9 (+/- SEM) years of age (range, 15 to 50 years), underwent heart transplantation preceded by the use of mechanical circulatory support. The causes of cardiac failure were ischemic (four), viral cardiomyopathy (three), idiopathic cardiomyopathy (two), congenital heart disease (one), and valvular heart disease (one). All patients were preterminal. Mechanical circulatory support consisted of intra-aortic balloon pump (eight), the total artificial heart (seven), biventricular assist (three), and left ventricular assist (two). Seven patients had more than one form of support. The duration of mechanical circulatory support was 12.2 +/- 4.1 days (range, 1 to 44 days). Once listed for transplantation, patients waited for 8.1 +/- 2.4 days for a donor. Seven patients received OKT3 monoclonal antibody as prophylaxis, in addition to triple-drug immunosuppression. There were four rejection episodes and 12 serious infections. In addition, eight patients suffered a major posttransplant complication of a distant organ system: central nervous system (three), renal (two), and respiratory (three). Post transplant hospitalization was 48 +/- 22 days (range, 15 to 248 days). Two patients (18%) died after transplant, one of severe acute rejection (29 days) and one of multisystem failure (248 days). All patients surviving transplant hospitalization are alive 6 to 34 months after the transplant procedure. Eight patients are in functional class I and 1 patient class II. This patient attends school full-time but has a premechanical support system neurologic defect. In follow-up of 163 patient-months except for yearly catheterization, these nine patients required only 5 hospital days. Although the use of the mechanical circulatory support as a bridge to transplantation can result in a prolonged, complicated hospitalization after transplant, the long-term results are gratifying.