Chugging to silent machines: development of mechanical cardiac support
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REVIEW ARTICLE
Chugging to silent machines: development of mechanical cardiac support Cumaraswamy Sivathasan 1 Received: 7 May 2020 / Revised: 1 July 2020 / Accepted: 2 July 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
Abstract The concept of a mechanical device to support failing hearts arose after the introduction of the heart lung bypass machine pioneered by Gibbon. The initial devices were the pulsatile paracorporeal and total artificial heart (TAH), driven by noisy chugging pneumatic pumps. Further development moved in three directions, namely short-term paracorporeal devices, left ventricular assist devices (LVADs), and TAH. The paracorporeal pumps moved in the direction of electrically driven continuous-flow pumps as well as catheter-mounted intracardiac pumps for short-term use. The LVAD became the silent durable electric, implantable continuous-flow pumps. The TAH remains a pneumatically driven pulsatile device with limited application, but newer technology is moving toward electrically operated TAH. The most successful pumps are the durable implantable continuous-flow pumps now taken over by the 3rd-generation pumps for the bridge to transplant and long-term use with significantly improved survival and quality of life. But bleeding including gastrointestinal bleeding, strokes, and percutaneous driveline infections exist as troublesome issues. Available data supports less adverse hemocompatibility of HeartMate 3 LVAD. Eliminations of the driveline will significantly improve the freedom from infections. Restoring physiological pulsatility to continuous-flow pumps is in the pipeline. Development of appropriate right VAD, miniaturization, and pediatric devices is awaited. Poor cost-effectiveness from the cost of LVAD needs to be resolved before mechanical cardiac support becomes universally available as a substitute for heart transplantation. Keywords Mechanical cardiac support . Left ventricular assist device . Total artificial heart . Heart transplantation . Heart failure . Bridge to transplantation . Destination therapy
Introduction Globalization has resulted in an epidemiologic transition in developing countries, from infectious disease and nutritional deficiencies, to non-communicable diseases such as hypertension, coronary artery disease, diabetes, and obesity [1]. Even in India, cardiovascular diseases (CVD) have become the leading cause of mortality. A quarter of all mortality is attributable to CVD. Ischemic heart disease and stroke are the predominant causes and are responsible for more than 80% of CVD deaths [2]. With the increasing incidence of CVD and the aging population, the burden of heart failure (HF) is likely to rise [3]. Although both * Cumaraswamy Sivathasan [email protected] 1
Mechanical Cardiac Support and Transplantation, National Heart Centre, Singapore, Singapore
pharmacological and non-pharmacological therapies are available, HF usually requires life-long medications. In fact, India contributed to the finding that neuroendocrine activation occurs in HF
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