Implantable Artificial Heart Research Articles

A Bridged Approach to Heart Transplantation Using ECMO and Total Artificial Heart Implantation

Purpose The rapid increase of the use of extracorporeal membrane oxygenation (ECMO) as a direct bridge to heart transplantation (HT) raises concerns. The objective of this study is to describe the outcomes after HT using a bridge-to-bridge strategy with a sequence of ECMO support followed by temporary total artificial heart (t-TAH) implantation. Methods A retrospective, multicentric analysis of 54 patients who underwent t-TAH (SynCardia) implantation following the use of an ECMO for cardiogenic shock was performed (ECMO-t-TAH group). A control group of 163 patients who underwent t-TAH implantation as a direct bridge to transplantation (t-TAH group) was used to assess the impact of this strategy. Results Fifty-four patients, averaging 47±13 years old underwent implantation of a t-TAH after 5.3±3.4 days of ECMO perfusion for cardiogenic shock. In the ECMO-t-TAH group, 20 patients (20/54,37%) died after t-TAH implantation and 57 patients (57/163,35%) died in the t-TAH group (p=0.4968). Overall, 32 patients (32/54, 59%) underwent heart transplantation in the ECMO-t-TAH group, compared to 106 patients (106/163, 65%) in the t-TAH group (p=0.4449). No significant difference in survival was observed at 6 months, 1 and 3 years after heart transplant (ECMO-t-TAH group: 94%, 87%, and 80% vs. 87%, 83%, and 76% in the t-TAH group, respectively). Deterioration of liver function tests under t-TAH was associated with increased mortality before heart transplant in both groups. Conclusion The present series suggests that sequential bridging from ECMO to t-TAH followed by heart transplantation is a viable alternative for a group of highly selected patients.

Agreement between Anti-Factor Xa and Activated Partial Thromboplastin Time Measurements in Syncardia Total Artificial Heart Recipients Receiving Postoperative Anticoagulation with Unfractionated Heparin

<h3>Purpose</h3> The Activated Partial Thromboplastin Time (aPTT) has been the historical method of choice for anticoagulation monitoring in patients undergoing mechanical circulatory support with intravenous unfractionated heparin (IVUFH). However, the assay is susceptible to interference effects and is being progressively superseded by the anti-Factor Xa (anti-Xa) method. The study aim was to investigate the agreement between aPTT and anti-Xa measurements in patients receiving post-operative anticoagulation with IVUFH following Syncardia Inc. Total Artificial Heart (TAH) implantation. <h3>Methods</h3> A retrospective single arm, single centre analysis of 20 patients who underwent TAH implantation from July 2014 to October 2018 entailed simultaneous determinations of aPTT and anti-Xa. Agreement between these parameters was assessed using a novel statistical approach based on the Bland-Altman method. <h3>Results</h3> In spite of a positive correlation between aPPT and anti-Xa measurements, normal target ranges were poorly aligned: from 5^th to 30^th post-operative day, for anti-Xa values of 0.2 and 0.4 U/mL corresponding APTT values were 51.1 and 64.3 seconds, respectively. Moreover, white blood cell count was associated with a trend towards lower aPTT levels with respect to anti-Xa. Conversely, bilirubin level was significantly associated with an increase in aPTT levels with respect to anti-Xa values. <h3>Conclusion</h3> A novel method developed to investigate the agreement between aPTT and anti-Xa in the peri-operative phase of TAH therapy showed comparatively low levels of anticoagulation (with respect to historical target aPTT range) were not associated with thromboembolic sequalae. Methodology developed for this study is generalisable to other forms of mechanical circulatory support.

Outcomes after Heart Transplantation and Total Artificial Heart Implantation: A Multicenter Study

Outcomes after Heart Transplantation and Total Artificial Heart Implantation: A Multicenter Study

Outcomes after heart transplantation and total artificial heart implantation: A multicenter study

We sought to assess the outcomes after heart transplantation (HT) of patients supported with a temporary total artificial heart (t-TAH) as a bridge to transplantation in high-volume centers. A retrospective analysis of 217 consecutive patients who underwent t-TAH (SynCardia Systems, Tucson, Arizona) implantation between January 2014 and May 2019 in 6 high-volume North American centers was performed. End points included survival and adverse events after t-TAH and HT. The mean age of patients was 49 ± 12 years, and heart failure etiologies were non-ischemic dilated cardiomyopathy (36%), ischemic (25%), restrictive (12%), and cardiac graft failure (9%). A total of 101 (48%) patients had Interagency Registry for Mechanically Assisted Circulatory Support patient profile 1, and 65 (31%) had Interagency Registry for Mechanically Assisted Circulatory Support patient profile 2. At the end of the study period, 138 of 217 (63.5%) patients had undergone HT, and 75 (34.5%) patients died before HT. The mean time between t-TAH implantation and HT averaged 181 ± 179 days (range: 0-849) and the mean follow-up after HT was 35 ± 25 months. The overall survival in the entire cohort was 75%, 64%, and 58% at 1, 2, and 5 years, respectively. Post-transplant survival was 88%, 84%, 79%, and 74% at 6 months, 1 year, 2 years, and 5 years, respectively. Among the 32 patients (23%) who died after HT, the main causes of death were chronic allograft vasculopathy (25%), multiorgan failure (21.8%), sepsis (15.6%), and stroke (9%). In this multicenter study, almost two thirds of patients implanted with a t-TAH could be transplanted. The overall and post-transplantation survival after t-TAH was satisfactory in these critically ill patients.

Implantation of two HeartMate 3s in the setting of a Total Artificial Heart

Irreversible, end-stage biventricular heart failure is associated with mortality rates of up to 100%. Despite the increasing application of ventricular assist devices (VADs), many centers lack experience with total artificial heart (TAH) implantation techniques. We present a surgical technique consisting of the implantation of 2 HeartMate 3 VADs in the setting of a TAH as a bridge to transplantation strategy.

Successful venoplasty of superior vena cava stenosis in a patient with a total artificial heart after orthotopic heart transplantation due to primary graft failure

With the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short- and long-term mechanical circulatory support devices, including the implantation of total artificial hearts (TAHs) are modalities that are increasingly being used as treatment options for patients with end-stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH. A 65-year-old man with a history of nonischemic cardiomyopathy had received a left ventricular assist device, and then 2 years later, underwent orthotopic heart transplantation using the bicaval anastomosis technique. The postprocedural course was complicated by primary graft failure, resulting in the need for implantation of a TAH. About 5 months after TAH implantation, he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal, and liver function. Potential fatal complications caused by catheter or wire entrapment in the right-sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH.

CARMAT total artificial heart implantation: report on the first successful clinical experience as bridge to heart transplantation

CARMAT total artificial heart implantation: report on the first successful clinical experience as bridge to heart transplantation

Predictors of Renal Failure in Patients Treated With the Total Artificial Heart

The incidence of hemodialysis (HD)-dependent renal failure after total artificial heart (TAH) implantation is high. We sought to determine the preoperative predictors of HD after TAH implantation. We studied 87 patients after TAH implantation at our institution between April 2006 and March 2017. Baseline clinical data were obtained from the medical records, and patients were followed until death or heart transplantation. We performed logistic regression analysis to identify predictors of HD after TAH implantation. Of the patients, 24 (28%) required postimplantation HD. Those requiring HD were more likely to have histories of coronary artery disease (58% vs 29%; P = 0.01), required preoperative membrane oxygenation (33% vs 4.8%; P = 0.001) and had lower baseline estimated glomerular filtration rates (54 ± 29 vs 67 ± 24 mL/min/1.73m2; P = 0.04). Patients requiring HD were at a higher risk of death on device at 1 year (33% vs 5%, P = 0.001; log rank test: P =0.001, hazard ratio 6.6 [95% CI:1.8-23], P = 0.003). The incidence of postimplantation HD is high and is associated with increased likelihood of mortality. Lower baseline estimated glomerular filtration rates, histories of coronary artery disease and preoperative membrane oxygenation support are predictors of postimplantation requirement of HD. These data may help to identify patients at risk for adverse outcomes after TAH implantation.

Impact of Bleeding Complications on Outcomes Following Total Artificial Heart Implantation

Bleeding complications are well recognized phenomena following left ventricular assist device (LVAD) implantation and have been associated with increased morbidity and mortality. This complication and its consequences, however, remain undefined for total artificial heart (TAH) implantation. A prospectively maintained database was used to identify all patients receiving TAH from January 2012 to May 2019 at a single institution. Baseline demographics and outcomes were retrospectively reviewed. The INTERMACS definition of major bleeding was used for stratification. Ninety-three patients underwent TAH implantation (age 50.0 ± 12.8, male 82.8%) between January 2012 and May 2019. The predominant cardiac diagnoses were idiopathic dilated cardiomyopathy (n=39, 41.9%), ischemic dilated cardiomyopathy (n=23, 24.7%), and restrictive cardiomyopathies (n=14, 15.1%). Most patients were INTERMACS profiles 1 and 2 (53% and 31%, respectively). The overall survival was 62.4%, with a median follow-up of 1.5 years [0.1, 4.2]. Fifty-six patients (60.2%) were successfully bridged to transplantation, with 1-year post-transplant survival of 91.1%. Thirty-four patients (36.6%) experienced major bleeding. There were no significant differences in baseline demographics, disease etiology, or INTERMACS profiles between the bleeding and non-bleeding cohorts. A trend towards increased overall mortality (HR 1.54 [0.84-2.81], p=0.143) and decreased rates of transplantation (50% vs 66%, p=0.185) were noted in the major bleeding cohort. Post-transplant survival at 1-year were 82.4% and 94.9% in the bleeding and non-bleeding cohorts, respectively (p=0.158). Three rejection episodes (17.6%) were noted in the bleeding cohort and 6 (15.4%) in the non-bleeding cohort (p>0.999). Major bleeding events occurred in over one-third of patients undergoing TAH implantation. This complication, however, did not appear to significantly impact survival or allograft rejection rates.

HeartMate 3 as Total Artificial Heart for the Treatment of Biventricular Heart Failure as Bridge to Transplantation

Despite maximal medican and surgical therapy, the outcomes of severe biventricular failure remain poor with mortality rates of up to 100%. The only definite therapy option for this disease is the total replacement of the heart - either by cardiac transplantation or by total artificial heart (TAH) implantation. Due to the lack of donor organs, mechanical assist devices are the most relevant option for these patients. The permanent availability of mechanical devices is especially attractive in emergency cases as well as in high-risk patients. The placement of two HeartMate 3 in the setting of a TAH is an alternative approach to pulsatile TAH implantation. We now present the worldwide first series of outcomes of this novel procedure. We performed a retrospective analysis of seven consecutive patients who underwent off-label HeartMate 3 TAH implantation after cardiectomy at two international medical institions. Data was acquired using the in-house clinical databases. Follow-up time was thirty days postoperatively. Among perioperative baseline characteristics, adverse events and survival data were collected and analyzed. The retrospective study was approved by the loca institutional ethics committee. Out of 7 patients 4 were male (57%). Primary diagnosis was dilated cardiomyopathy in four cases (4/7, 57%) Other diagnoses were stone heart syndrome, restrictive cardiomyopathy and post-partum cardiomyopathy. All patients were previously supported by ECMO. 3 patients suffered from severe ventricular thrombosis. Intraoperative mortality was 0%. One patient was successfully transplanted after 71 days on device. One patient is still on-going on the device, currently discharged and waiting for heart transplantation (POD 259). Full mobility was achieved in both patients. In all cases postoperative hemodynamic stability was successfully achieved. No device related technical complications occured. Four patients died within thirty days of support (51%; POD 10-21). Causes of death were sepsis and multi-organ failure (3/4) and stroke (1/4). It has been proven that the implantation of two HeartMate 3 VADs in the settings of a total artificial heart is a feasible concept with no technical adverse events in our patient population. In this high risk patient cohort, a reduction of 30-day-mortality from 100% to 57% was achieved.

Outcome differences in acute vs. acute on chronic heart failure and cardiogenic shock.

AimsDespite advances in coronary reperfusion and percutaneous mechanical circulatory support, mortality among patients presenting with cardiogenic shock (CS) remains unacceptably high. Clinical trials and risk stratification tools have largely focused on acute CS, particularly secondary to acute coronary syndrome. Considerably less is understood about CS in the setting of acute decompensation in patients with chronic heart failure (HF). We sought to compare outcomes between patients with acute CS and patients with acute on chronic decompensated HF presenting with laboratory and haemodynamic features consistent with CS.Methods and resultsSequential patients admitted with CS at a single quaternary centre between January 2014 and August 2017 were identified. Acute on chronic CS was defined by having a prior diagnosis of HF. Initial haemodynamic and laboratory data were collected for analysis. The primary outcome was in‐hospital mortality. Secondary outcomes were use of temporary mechanical circulatory support, durable ventricular assist device implantation, total artificial heart implantation, or heart transplantation. Comparison of continuous variables was performed using Student's t‐test. For categorical variables, the χ 2 statistic was used. A total of 235 patients were identified: 51 patients (32.8%) had acute CS, and 184 patients (64.3%) had acute decompensation of chronic HF with no differences in age (52 ± 22 vs. 55 ± 14 years, P = 0.28) or gender (26% vs. 23%, P = 0.75) between the two groups. Patients with acute CS were more likely to suffer in‐hospital death (31.4% vs. 9.8%, P < 0.01) despite higher usage of temporary mechanical circulatory support (52% vs. 25%, P < 0.01) compared with patients presenting with acute on chronic HF. The only clinically significant haemodynamic differences at admission were a higher heart rate (101 ± 29 vs. 82 ± 17 b.p.m., P < 0.01) and wider pulse pressure (34 ± 19 vs. 29 ± 10 mmHg, P < 0.01) in the acute CS group. There were no significant differences in degree of shock based on commonly used CS parameters including mean arterial pressure (72 ± 12 vs. 74 ± 10 mmHg, P = 0.23), cardiac output (3.9 ± 1.2 vs. 3.8 ± 1.2 L/min, P = 0.70), or cardiac power index (0.32 ± 0.09 vs. 0.30 ± 0.09 W/m2, P = 0.24) between the two groups.ConclusionsCurrent definitions and risk stratification models for CS based on clinical trials performed in the setting of acute coronary syndrome may not accurately reflect CS in patients with acute on chronic HF. Further investigation into CS in patients with acute on chronic HF is warranted.

P239 Total artificial heart implantation as a bridge to candidacy - an approach to treating primary cardiac sarcoma?

Abstract Background Primary cardiac tumors are rare entities, only 25% of them are malignant. Most common malignant neoplasms of the heart are sarcomas - aggressive tumors with a high rate of local recurrence and systemic metastases. They may lead to a rapid clinical deterioration and sudden circulatory collapse due to obstruction of the intracardiac outflow tract. Most patients affected are younger than 65 years of age. Early diagnosis of cardiac tumors is challenging, echocardiography remains a mainstay of their evaluation. The prognosis is very poor, most patients succumb to disease within months of diagnosis. Complete surgical resection and adjuvant chemotherapy offers palliation and improves survival. Total artificial heart implantation (TAH) allows through, radical resection of large tumors yielding the best possible outcome. Case presentation A 58-year-old male patient with a history of hypertension was admitted to our hospital with a chief complaint of worsening dyspnea and fatigue for last several weeks. Echocardiogram demonstrated a large cardiac mass with abundant vascular supply that incorporated the whole right ventricle and intraventricular septum, extended to the tricuspid valve, infiltrated the left ventricle apex and the base of posterior tricuspid leaflet. The right ventricle cavity was slit-like with small gradient in the outflow track. Cardiac magnetic resonance suggested angiosarcoma or lymphoma. PET-CT did not reveal any extracardiac metastases at that time. The case was discussed at our multidisciplinary cardio-oncology conference. The radical resection of the mass with subsequent TAH implantation was decided upon in high-risk setting, with feasible long-term survival, including eventual consideration for cardiac transplantation (HTX). Native ventricles were excised at the atrioventricular level down to the annulus of the mitral and tricuspid valves. The artificial ventricles were connected to the atrial remnants. The ascending aorta and the main pulmonary artery were dissected close to the valves and connected to outflow grafts. Histopathologic examination of the mass demonstrated angiosarcoma. The patient was started on paklitaksel. After completion of his chemotherapy regimen his eligibility for HTX will be reevaluated. Conclusion Diagnosis and therapy of sarcomas are challenging. Their rarity makes it difficult to standardize therapy. There is few evidence available in literature to guide the treatment of such patients. Case-specific, heart-team-based strategy must be adopted to aid decision making in this rare cases. Sarcomas are lethal, develop rapidly and affect fairly young patients. Prompt surgical resection with subsequent TAH implantation and adjuvant chemotherapy seems ideal in this situation as it offers a possible cure. It gives a slim chance of long-term survival after consecutive HTX for chemotherapy responders. Abstract P239 Figure. Angiosarcoma in TTE, MRI and TEE.

The Biocompatibility Challenges in the Total Artificial Heart Evolution.

There are limited therapeutic options for final treatment of end-stage heart failure. Among them, implantation of a total artificial heart (TAH) is an acceptable strategy when suitable donors are not available. TAH development began in the 1930s, followed by a dramatic evolution of the actuation mechanisms operating the mechanical pumps. Nevertheless, the performance of TAHs has not yet been optimized, mainly because of the low biocompatibility of the blood-contacting surfaces. Low hemocompatibility, calcification, and sensitivity to infections seriously affect the success of TAHs. These unsolved issues have led to the withdrawal of many prototypes during preclinical phases of testing. This review offers a comprehensive analysis of the pathophysiological events that may occur in the materials that compose TAHs developed to date. In addition, this review illustrates bioengineering strategies to prevent these events and describes the most significant steps toward the achievement of a fully biocompatible TAH.

Trends in utilization, mortality, major complications, and cost after total artificial heart implantation in the United States (2009-2015)

ObjectiveTotal artificial heart (TAH) is a viable bridge to transplant (BTT) strategy for patients with severe biventricular failure or complex congenital heart disease. These patients have higher mortality and morbidity than patients undergoing left ventricular assist device (LVAD) implantation. To assess national trends in in-hospital mortality, major complications, cost, length of stay, and disposition of patients undergoing TAH implantation. MethodsData from the National Inpatient Sample, the largest all-payer inpatient data set in the United States, and the US Census Bureau, for the years 2009 to 2015 were analyzed. Participants included all adult patients who received TAH from 2009 to 2015. Endpoints included in-hospital mortality, in-hospital complications, heart transplantation (HT) in the same admission, length of stay, cost, and disposition at the time of discharge. ResultsWe identified a total of 143 (weighted = 703) TAH implantations. The number of TAH implants increased during the study period (average annual change +5.8%, p = 0.03). Rates of in-hospital mortality and major complications including ischemic stroke, major bleeding, postoperative infections, acute kidney injury requiring dialysis, and HT did not change significantly over the study period. Although the length of stay and disposition patterns did not change over time, we found a significant increase in cost of hospitalization (average annual change +44,362, p = 0.01). The number of HT during the same hospital stay decreased significantly (average annual change −8.1%, p = 0.02). ConclusionIn-hospital mortality and complication rates associated with TAH implantation remain increased and did not change in the era of continuous flow LVADs.

SynCardia, total artificial heart, as a bridge to transplant.

Implantation of a total artificial heart is an alternative to durable biventricular assist device support in selected patients. We present our initial experience with the implantation of the SynCardia total artificial heart (TAH) in three patients. The first patient, was the first SynCardia (TAH) implantation in the Visegrad Four (V4) countries METHOD: Three patients with severe refractory end stage biventricular heart failure listed for heart transplant were indicated for SynCardia TAH implantationRESULTS: We present in details the perioperative and postoperative outcomes of these patients. The first and the third patient, after 195 and 126 days of TAH support respectively, had asuccessful heart transplants, the second patient died on 11th postoperative day. The cause of death was brain bleeding due to ruptured undiagnosed brain aneurysm. SynCardia TAH is an alternative therapy in patients with end-stage biventricular heart failure waiting for heart transplantation. The SynCardia TAH with pulsatility resembles the physiologic circulation, improves the condition of the patients and increases survival compared to the biventricular assist devices. It is an intermediate step until the development of genetically modified animal hearts, engineered bioartificial hearts or hearts from induced pluripotent stem cells that would replace the failing heart in the patients with end-stage heart disease (Tab. 2, Fig. 1, Ref. 27).

Total artificial heart implantation as a bridge to transplantation: a viable model for the future?

ABSTRACTIntroduction: Since the first total artificial heart (TAH) surgery in a human patient performed in 1969, over 1300 devices have been implanted worldwide. Patients are benefiting from increased lengths of durable support and indications have expanded beyond biventricular failure including allograft failure, severe restrictive disease, and complex congenital anomalies.Areas covered: The role of the TAH in biventricular failure, rates of successful bridge-to-transplant (BTT), and survival compared with biventricular assist devices (BiVADs) are discussed and differences between TAH and LVAD patient populations are highlighted. The device’s niche role in physiologies not amenable to single ventricle support is further described. New developments such as the 50cc Syncardia, continuous flow mechanisms (BiVACOR and Cleveland Clinic CF-TAH), and a bioprosthetic model (CARMAT) are discussed.Literature review was conducted utilizing the PubMed database selecting published research, database analyses, and case reports under ‘total artificial heart’ relevant to the paper’s aims.Expert commentary: TAH patients have high rates of successful BTT and survival on par with BiVAD-supported patients. Ongoing developments including decreased device size, continuous flow mechanisms, and use of bioprosthetic materials will ensure that the TAH will have an increasing role in advanced heart failure with increased device longevity and decreased post-implant complications.

Electrical power to run ventricular assist devices using the Free-range Resonant Electrical Energy Delivery system.

Models of power delivery within an intact organism have been limited to ionizing radiation and, to some extent, sound and magnetic waves for diagnostic purposes. Traditional electrical power delivery within the intact human body relies on implanted batteries that limit the amount and duration of delivered power. The efficiency of current battery technology limits the substantial demands required, such as continuous operation of an implantable artificial heart pump within a human body. The fully implantable, miniaturized, Free-range Resonant Electrical Energy Delivery (FREE-D) system, compatible with any type of ventricular assist device (VAD), has been tested in a swine model (HVAD) for up to 3 hours. Key features of the system, the use of high-quality factor (Q) resonators together with an automatic tuning scheme, were tested over an extended operating range. Temperature changes of implanted components were measured to address safety and regulatory concerns of the FREE-D system in terms of specific absorption rate (SAR). Dynamic power delivery using the adaptive tuning technique kept the system operating at maximum efficiency, dramatically increasing the wireless power transfer within a 1-meter diameter. Temperature rise in the FREE-D system never exceeded the maximum allowable temperature deviation of 2°C (but remained below body temperature) for an implanted device within the trunk of the body at 10 cm (25% efficiency) and 50 cm (20% efficiency), with no failure episodes. The large operating range of FREE-D system extends the use of VAD for nearly all patients without being affected by the depth of the implanted pump. Our in-vivo results with the FREE-D system may offer a new perspective on quality of life for patients supported by implanted device.

Treatment of cardiac synovial sarcoma: experience of two cases

BackgroundPrimary heart sarcomas are exceedingly rare tumors. Among primary cardiac sarcomas, synovial sarcoma is one of the rarest, involving cardiac cavities or pericardium.Case presentationTwo cases of synovial sarcoma are presented with the clinical course and therapy. Both cases were treated with surgery and chemo/radiotherapy. Interestingly, one of the patient, a 52-year-old male with an intracardiac synovial sarcoma, undergone a SynCardia total artificial heart implantation, but died for multiple pulmonary metastases waiting for transplantation.ConclusionComplete surgical resection of cardiac synovial sarcoma is the gold standard of therapy, though rarely possible. Although guidelines for the treatment are not well established, due to limited number of cases reported, chemotherapy and radiotherapy are frequently administered and seem to prolong mean patient’s survival. Cardiac transplantation could be considered in selected cases.

Lumbar muscle atrophy caused by harness replacement in a chronic calf model of total artificial heart implantation.

The postoperative care of animals implanted with mechanical circulatory support devices is complex. The standard of care requires continuous monitoring of hemodynamic parameters post implant, wound care, and maintenance of the animal's well-being, but also includes controlling the animal's biomechanics under conditions of continuous restraint and harnessing. In such studies, a harness provides secure fixation of the exteriorized device driveline and pressure lines and aids animal handling (lifting, position adjustment, and assistance with standing up). Harnessing is a key element in large-animal surgery. It affects the animal's conditions, safety, and post-procedure troubleshooting and thus may drastically worsen postoperative outcomes if improperly handled. Here we report a case associated with an unplanned harness replacement in a chronic animal model implanted with the Cleveland Clinic continuous-flow total artificial heart. Inadvertent changes to the harness resulted in posture change caused by muscular atrophy of the calf's spine that had been under long-term harness support.

Long-Term Mechanical Circulatory Support vs Heart Transplant: A Half-Century of Progress, but When Will the Tin Man Arrive?

In L. Frank Baum's Wonderful Wizard of Oz, Dorothy, blown out of Kansas by a tornado, finds the rusted Tin Man in a forest, reanimates him with the contents of his oil can, and troops off to the Emerald City, joined by the Scarecrow and Cowardly Lion, to get a heart from the Wizard for her new acquaintance. This allegorical tale published in 1900 has been said to represent many things, but for our profession, it can characterize the present-day magic and mysticism of heart transplant, ventricular assist devices, and, in particular, total artificial heart implantation. 1 Baum L.F. The Wonderful Wizard of Oz. George M. Hill Company, Chicago1900 Google Scholar Thus, the forward-looking title of this retrospective “bookend” reflection.