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Ann Thorac Surg 2000;70:59-66
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Mechanical assist strategy using the BVS 5000i for patients with heart failure

^a Division of Cardiothoracic Surgery, University of California Medical Center, Los Angeles, California, USA

Address reprint requests to Dr Marelli, Division of Cardiothoracic Surgery, UCLA School of Medicine, 10833 Le Conte Ave, 62-238 CHS, Box 951741, Los Angeles, CA 90095-1741
e-mail: dmarelli{at}mednet.ucla.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment Appendix A Appendix B References

 
Background. The BVS 5000i external pulsatile assist device is used to support patients with reversible cardiogenic shock. Its low cost and potential for insertion without cardiopulmonary bypass make it an attractive option.

Methods. Nineteen status I patients failing inotropic support were treated with the BVS 5000i with the intention of short-term bridge to transplant. Fourteen patients received left ventricular support whereas 5 received biventricular support. Cardiopulmonary bypass was used in less than 50% of patients.

Results. Median support time was 7 days. The 2 myocarditis patients were weaned from support. Twelve patients were transplanted and there were 5 deaths on support. Overall 14 of 19 were transplanted or weaned. One-year survival was 79%. Median hospital stay was 31 days.

Conclusions. The BVS 5000i can be used for short-term mechanical assist toward transplantation in selected patients for whom a donor can be expected soon. The device may provide a cost-effective, short-term strategy to optimize end-organ function before orthotopic heart transplant, particularly for patients who are predictably not ideal to be discharged with implantable left ventricular assist device treatment.

	Introduction

Top Abstract Introduction Material and methods Results Comment Appendix A Appendix B References

 
The growing number of patients waiting for transplants and the stagnant number of suitable organs available have led to an increase in transplant waiting time [1]. This has necessitated the use of mechanical cardiac assist devices aimed at preventing end-organ deterioration of United Network for Organ Sharing (UNOS) status I patients while waiting for transplantation. Commonly used left ventricular pulsatile cardiac assist devices (LVAD) can be divided into two categories: internal implantable (eg, Heartmate, Thermo Cardiosystems, Woburn, MA), which offer the possibility of outpatient treatment, and external (eg, BVS 5000i, Abiomed, Danvers, MA; and Thoratec Ventricular Assist Device System, Thoratec Laboratories, Pleasanton, CA) [2]. Internal VADs also comprise nonpulsatile centrifugal pumps. Advantages of the implantable LVADs include safety for long-term use and maximum patient mobility. The main disadvantages are the high costs and the increased risk with such an extensive operation, which requires abdominal implantation and the need for cardiopulmonary bypass (CPB). Depending on the timing of surgery, this results in a longer postoperative recovery period in the intensive care unit (ICU) and a potential further depletion of end-organ reserve in the early postoperative period. The use of the Heartmate implantable LVAD in severely compromised status I patients has resulted in survival to transplant of 76% and an overall 1-year survival of 68.4% [3]. In another report, survival to transplantation or explant was 75% [4].

The BVS 5000i external pulsatile VAD is typically used for short-term mechanical support in postcardiotomy patients with cardiogenic shock or in other situations when myocardial recovery is expected [5]. It has a small console that can provide biventricular support and does not require specialized bedside personnel. Two attractive features of this assist device are its low cost and the option to institute support without CPB. Theoretically, avoiding CPB should lead to shorter postoperative recovery of end-organ function. We hypothesized that this device would be ideal for certain heart failure patients with limited end-organ dysfunction and who would not require long waiting times for a donor heart.

We report our experience with the BVS 5000i as a bridge to orthotopic heart transplant (OHT) for smaller patients with severe congestive heart failure (CHF) and end-organ dysfunction, who require short-term optimization before OHT.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Appendix A Appendix B References

 
Nineteen patients, aged 8 to 67 years, were supported on the BVS 5000i. Excluding 2 postcardiotomy patients, 4 had previous remote surgery. Clinical characteristics are summarized in Table 1. Raw data are listed in Appendices A and B. Preimplant status is summarized in Table 2. Ejection fractions at the time of referral ranged from 10% to 20%. Median cardiac index was 1.79 L/m² (range 1.03 to 4.0). Eight patients had an intraaortic balloon pump. All were UNOS status I on maximal inotropic support defined as two or more intravenous agents at maximal dosages.

BVS 5000i device
The BVS 5000i device is an external pulsatile pump that is pneumatically driven [6]. It consists of a polyurethane chamber in a polycarbonate housing. The atrium of the pump is filled by gravity and empties passively after the ventricle contracts. It supplies blood to a ventricle from which it is separated by a one-way valve. When the ventricle fills with 80 mL of blood, it generates a pressure that is sensed by the console that immediately sends compressed air back to the pumping chamber, causing the bladder to eject its volume. Unidirectional flow is ensured by the presence of one-way valves similar to a human heart.

Left ventricular (LV) assist is achieved using a cannula graft with an extension sewn onto the aorta. The ascending aorta is dissected at its distal portion and a side-biting clamp is applied after heparin is given to achieve an activated clotting time of 300 seconds if the procedure is to be done off bypass. Previous coronary grafts are carefully preserved. The arterial inflow graft is then anastomosed in an end-to-end fashion to the aorta with a running 4 to 0 Prolene suture and reinforced with a pericardial strip (Fig 1). In most cases, the left atrial cannula is inserted into the right superior pulmonary vein. We have occasionally used the left atrial appendage (in younger patients) or the dome of the left atrium when it is very large. The cannulas are positioned away from the heart and tunneled through the abdominal wall to allow for chest closure without compression of the right ventricle (Fig 2). Two patients had LV apical cannulation. One of these patients, with severe dilated cardiomyopathy (CM), had the cannula placed off CPB via a small left anterior thoracotomy in addition to a sternotomy. The other had an LV apical cannulation on CPB following a failed revascularization for chronic ischemic CM. Our preference is to use the malleable 36F open-end cannula for all intracardiac cannulations, making sure the bevel is pointing away from the septum of the chamber of insertion.

View larger version (61K): [in this window] [in a new window]   Fig 1. The outflow cannula graft is sewn end-to-side on the ascending aorta. The suture line is reinforced with a strip of pericardium for better hemostasis. Insert: An additional pursestring can be used in the adventitia of the aorta to relieve tension off the graft anastomosis during ventricular assist device pulsatile flow.

View larger version (39K): [in this window] [in a new window]   Fig 2. Exit sites for cannulas are placed carefully to avoid compression of the heart during chest closure.

The device’s internal rate is set by cyclic filling and it self-adjusts to maintain a stroke volume of 80 mL. It is usually slightly slower than the patient’s native rate. The blood chambers are suspended on a pole so that preload and afterload can be optimized for maximal output, which is usually greater than 5 L/min. In the ICU, filling pressures are adjusted to 8 to 12 mm Hg. Afterload is controlled with vasodilators. We aim for a mean systemic arterial blood pressure of 75 mm Hg to minimize the risk of cerebrovascular bleeding complications. Postoperatively, patients can be weaned off mechanical ventilation, can receive physiotherapy, and can receive normal diets. When pulmonary function recovers, they can ambulate within the ICU with assistance.

If base line panel reactive antibodies (PRA) are negative, transplantation without a donor/recipient crossmatch can occur within a week. After a week, however, a repeat PRA analysis is performed with a prospective crossmatch needed if treated PRAs are greater than 10%.

In all cases but one, the BVS 5000i was implanted via sternotomy. A thoracotomy was used in 1 patient as a precaution to avoid the risk of injuring patent bypass grafts inserted 1 year earlier. All patients underwent transesophageal echocardiography intraoperatively to rule out the presence of a patent foramen ovale. We attempted to insert the device off CPB in all patients when a patent foramen ovale was absent.

	Results

Top Abstract Introduction Material and methods Results Comment Appendix A Appendix B References

 
Fourteen of the 19 patients were treated with an isolated LVAD for hemodynamic support (Table 3). Five patients required biventricular support. RVAD was inserted off CPB in 3 of 5 patients. Eight patients (42%) required CPB at time of insertion, 2 of whom were the postcardiotomy patients who required support after the inability to come off of bypass. In the other 6 patients, CPB was necessary due to severe hemodynamic instability and impending cardiac arrest before surgery.

Twelve patients were transplanted after an average support time of 7 days. Four of these 12 received marginal donor hearts (see Comment). One patient died postoperatively of acute rejection and 1 of graft failure. The patient who died of graft failure received a marginal donor heart with myocardial contusion. This patient had received urgent BIVAD support after receiving cardiopulmonary resuscitation continuously on the way to the operating room. He had biventricular failure due to muscular dystrophy and was considered a poor candidate for an implantable LVAD.

The 12 survivors were discharged after an average hospital stay of 24 days postsupport (6 to 61 days). For the 14 patients who were transplanted or weaned, 30-day and 1-year actuarial survival was 85% and 79%, respectively (Fig 3).

View larger version (10K): [in this window] [in a new window]   Fig 3. Actuarial survival of transplanted patients.

Six patients developed renal failure and required dialysis, 4 of whom who died. Seven patients were extubated while on support. Seventeen of 19 patients achieved flows of 5 L/min while 1 patient had flows of 4 L/min, due to using the earlier generation BVS 5000i; flows were limited to 3 to 3.5 L/min in the small pediatric patient. Nine patients underwent reexploration for bleeding.

Creatinine levels were monitored daily to evaluate renal function (Fig 4). Over the duration of support, levels decreased or remained stable for 14 of 19 patients.

View larger version (30K): [in this window] [in a new window]   Fig 4. Serum creatinine levels. Each symbol corresponds to a specific patient.

View larger version (28K): [in this window] [in a new window]   Fig 5. Alveolar arterial (A-a) gradients. Each symbol corresponds to a specific patient.

	Comment

Top Abstract Introduction Material and methods Results Comment Appendix A Appendix B References

McCarthy and coworkers [3] reported on the use of the Heartmate implantable LVAD in 100 patients. Sixty-nine percent of their patients had ischemic CM. The mean duration of support was 70 ± 41 days (up to 206 days) and overall survival to heart transplantation was 76%. Overall, 1-year survival for the 100 patients was 67%. Fifty-eight percent of patients were found to have positive blood cultures whereas 28% had driveline infection. They concluded that the device provided excellent hemodynamic support but because of technical issues with the device and other postinsertion complications, cost was very high. Elevated creatinine before the insertion of the Heartmate was one of two significant risk factors for death before transplantation in multivariate analysis (1.8 versus 1.4 mg/dL, p = 0.05, odds ratio 2.4). The other risk factor that was significant was the use of extracorporeal membrane oxygenation (ECMO) preoperatively for resuscitation (33% versus 16%, p = 0.08, odds ratio 3.6).

Sun and coworkers [4] also recently reported the use of 100 Heartmate LVADs in 95 patients. Fifty-two patients received the pneumatic LVAD (five device changes) and 43 received the vented electrical model (four device changes). The mean duration of support was 108 days (0 to 605 days). Seventy percent were transplanted and 4% were weaned. Overall, mortality was 25%.

Recently, the Food and Drug Administration approved implantable electrical LVADs that allow for hospital discharge and are currently widely used. Nonhemodynamic criteria for insertion of these include a body surface area (BSA) of more than 1.5 m², and patients’ ability to manage the device. A 24-hour companion capable of managing the device is a prerequisite [7]. This treatment has several limitations in addition to the high device cost. Implantable devices required extensive surgery, including CPB, which may be too risky for certain patients such as those on ECMO or with secondary renal insufficiency, reflecting a late stage of CHF. Also, although most chronic heart failure patients can be treated only with a LVAD, as seen in this series, certain patients require BiVAD. Such patients therefore require external assist systems or a total artificial heart. Lastly, not all patients are candidates for discharge on an LVAD, especially those living in remote areas away from transplant centers. Body size to accommodate current implantable VADs has also been a concern in the past.

The BVS 5000i is a lower cost and less invasive potential alternative to implantable VADs. The average support time and total hospital length of stay for the transplanted/weaned patients in this series was 6.7 and 31 days, respectively. This time differs greatly from previous pneumatic Heartmate recipients at our institution who were supported for an average time of 115 days and had an average hospital length of stay of 150 days (unpublished data). These longer times pose greater costs and are partly attributed to longer transplant waiting times due to the typical use of the Heartmate in larger patients (average BSA 2.03 m²). In the present study, the overall wean/transplant rate was 74%. This rate suggests that in selected patients the BVS 5000i can provide comparable end results to implantable LVADs, with shorter total support time. By avoiding the need for abdominal wall dissection, and in many cases, CPB, the BVS 5000i may offer certain patients a decreased risk of postoperative complications. This advantage may translate into lower hospital costs, particularly if patients are to remain hospitalized until transplantation. The BVS 5000i may also shorten reactivation of UNOS status following a faster postoperative recovery. As discussed in the study by McCarthy and coworkers [3], a lower prechronic LVAD implant or preorgan transplant creatinine provides the patient a greater chance of survival. By optimizing end-organ function, including renal function, "off pump" BVS 5000i treatment may thus be useful in improving survival rates for high risk patients requiring mechanical support as a bridge to transplantation. Avoiding the heart-lung machine would prevent the aggravation of existing end-organ dysfunction. The requirement for anticoagulation therapy and limited patient mobility warrant the use of the BVS 5000i as a short-term device in a staging strategy for selected patients. This is well adapted to the current UNOS guidelines dividing status I patients into IA (short-term) or IB (long-term) subdivisions.

Other paracorporeal options for the patients presented in this study included centrifugal pumps and the Thoratec pulsatile system. A centrifugal pump does not provide pulsatile flow and requires specialized bedside personnel, thereby increasing the costs. The Thoratec system offers the possibility of both short-term and long-term support. However, as of this writing, outpatient treatment is currently not approved by the Food and Drug Administration and the cost of this device is significantly greater than that of the BVS 5000i.

The 5 deaths that occurred on support in this series were among patients who presented with severe cardiac dysfunction and worsening end-organ function. Patient "R.F." presented with renal and hepatic insufficiency. He had ischemic CM and several patent bypass grafts. The device was implanted off CPB via a lateral thoracotomy. At the time it was considered that he would have been a poor candidate for an implantable LVAD placed on CPB. He required reexploration for bleeding and the thoracotomy approach revealed itself to be cumbersome for this. We have since abandoned this approach and have been able to place the BVS 5000i off CPB in cases of redo sternotomy and previous coronary artery bypass graft surgery.

Patient "J.P.", aged 65 years, had a history of atrial fibrillation and a massive anterior wall myocardial infarction. After 3 weeks of unsuccessful medical treatment and worsening renal function in the ICU, the BVS 5000i was implanted. Unfortunately, at the time of implantation, the patient had dialysis-dependent renal failure. He was reexplored for tamponade on postoperative day 4 and died on postoperative day 6 as a result of MSOF.

Patient "W.M." presented an opportunity to be bridged to an implantable device. The patient was a 52-year-old man with dilated CM. Because he was referred with a creatinine level of more than 4.0 mg/dL, he underwent BVS 5000i placement off CPB. He was extubated and ambulatory (out of bed) postdevice implant, and exhibited improved end-organ function. Unfortunately, on day 9 of support, he experienced several cerebral vascular emboli postimplant due to heparin-induced thrombocytopenia. This precluded transplantation and he expired one day later. Because of his blood type B, our plan had been to support him for 14 days. If a donor heart had not become available during that time, we would have offered him an implantable LVAD.

Two patients underwent device placement due to postpartum CM and both died. Patient "S.S." was on multiple inotropic agents and an intraaortic balloon pump at time of LVAD insertion. An RVAD was later added. At time of withdrawal of support, the patient had pseudomonas pneumonia and liver dysfunction. Patient "E.S.," who also had only an LVAD initially, went into ventricular fibrillation. The patient’s chest was opened urgently and cardiopulmonary resuscitation was administered while a centrifugal RVAD was inserted. She was then converted to a BVS 5000i RVAD off CPB. She also developed heparin-induced thrombocytopenia presenting as disseminated intravascular coagulation, which required numerous transfusions of blood products. She developed respiratory distress syndrome and died of MSOF.

Indications for RVAD insertion at time of LVAD implant include CHF with pulmonary hypertension, rapidly progressive biventricular CHF (eg, giant cell myocarditis), or for patients with a history of cardiac arrest. Post-LVAD implant, flows less than 5 L/min indicate a failing right ventricle and necessitate the insertion of an RVAD, at least temporarily. In the 2 postpartum CM patients described above, RVADs were inserted post-LVAD insertion after evidence of right ventricular failure. We recommend to implant LVAD and RVAD simultaneously in postpartum CM patients to prevent the effects of a later failing right ventricle.

The use of the BVS 5000i for treatment of acute myocarditis was reported recently [9]. It was hypothesized that the device allows the heart to concentrate on using its metabolic energy for repair rather than work. In patients in whom the potential for recovery is not known, the BVS 5000i allows for the optimization of the patient in the event that transplantation becomes necessary. Because most myocarditis patients are not chronically ill, unlike many patients with CM, the device is useful for optimizing and maintaining end-organ reserves whereas long-term restoration is not typically needed. Such patients also present a particular technical challenge for insertion of large apical cannulas as their left ventricles are not enlarged. The 2 patients in the present series were listed for OHT. After 4 days of support, however, the patients appeared to have recovery of myocardial function, which improved steadily over the subsequent week, thus avoiding the need for transplantation.

Our strategy demonstrates that it is possible to bridge CHF patients with a potentially cost-effective, short-term strategy. When compared with a hospital stay that may be lengthened by a more complex implantable LVAD procedure, a short-term strategy with a total hospital stay of 30 days (including transplantation) is an attractive option, especially when there is advanced preoperative end-organ dysfunction. Our study did not compare the cost of short-term bridging in the ICU with the cost of long-term bridging out of the ICU, but in the hospital for several months. It is suggested, however, that in many cases it may be possible to shorten the process of mechanical bridge to transplant while maintaining equivalent results. Furthermore, our strategy avoids the delayed reoperation following chronic LVAD implant that can be complicated by severe adhesions. It also avoids the infectious complications associated with chronic LVAD therapy. UNOS has established new guidelines for the assignment of status codes for heart recipients [8]. Patients who have been on an LVAD or an RVAD or both for 30 days or less are considered to be status IA whereas those who have been on an assist device for more than 30 days are considered to be status IB. Figure 6 depicts a possible strategy for treating CHF, while maximizing organ usage. The BVS 5000i is ideal for use in critically ill status IA patients when a heart is expected soon. The advantage of the BVS 5000i can be assessed by taking into account body size, blood type, and regional status I listing. If a donor heart is not expected soon, the BVS 5000i can be used to optimize status IA patients before being converted to an implantable chronic LVAD for longer-term support, which results in a downgrade in UNOS status to IB after a total of 30 days of support. If a patient is in distress (status IB) and has preserved end-organ function an implantable chronic LVAD is the current accepted standard.

View larger version (27K): [in this window] [in a new window]   Fig 6. Algorithm for maintaining end-organ function in congestive heart failure patients incorporating the BVS 5000i for short-term mechanical support.

Our results suggest that the BVS 5000i can be used to optimize patients before conversion to a chronic implantable LVAD. Our study did not include such patients. We demonstrated that the use of the BVS 5000i in an intermediate staging strategy leading to heart transplantation may provide survival rates comparable to those achieved with implantable LVADs in selected patients. This strategy may also significantly reduce overall hospital stay for patients who are not discharged with an implantable LVAD.

	Appendix A

 
Patient characteristics

Patient No. Age (yrs) BSA (m2) Blood Type Diagnosis 1 41 1.82 A Post-MI 2 8 0.88 O S/p Fontan 3 59 1.95 A ICM 4 59 1.90 O ICM 5 34 1.94 B DCM 6 44 1.70 O Postcardiotomy 7 19 1.83 O PPCM 8 52 1.92 B DCM 9 65 1.76 O DCM 10 14 1.45 O DCM 11 42 1.60 A DCM 12 67 1.84 A ICM 13 32 1.80 O PPCM 14 20 1.58 O PPCM 15 17 1.50 O DCM 16 17 1.96 AB Myocarditis 17 25 1.54 O Myocarditis 18 15 1.75 O DCM 19 49 1.95 A Postcardiotomy

BiVAD = biventricular assist device; CPB = cardiopulmonary bypass;LVAD = left ventricular assist device; OHT = orthotopic heart transplant.

BSA = body surface area; DCM = dilated cardiomyopathy;ICM = ischemic cardiomyopathy; MI = myocardial infarction;PPCM = postpartum cardiomyopathy.

	Appendix B

 
Clinical data

Pt. AST (Units/ L) ALT (Units/ L) Total Bilirubin (mg/dL) BUN (mg/ dL) Creatinine (mg/dL) No. of Inotropes Mechanical Ventilation IABP or ECMO Device CPB Pre- support Support Post- recovery/ OHT Total 1 394 1665 1.7 127 3.7 3 Yes None LVAD Yes 5 d 4 d 31 d 40 d 2 71 53 2.9 34 0.9 4 Yes None LVAD No 16 8 25 49 3 107 63 2.2 103 2.8 4 No IABP LVAD No 2 9 0 11 4 42 18 1.5 40 4.6 2 No IABP LVAD No 6 6 7 19 5 19 22 3.2 78 1.7 2 No IABP LVAD No 14 4 14 32 6 73 15 3.0 15 1.0 3 Yes None LVAD Yes 5 3 22 30 7 113 ··· 1.7 65 1.8 3 Yes IABP LVAD Yes 0 4 31 35 8 21 11 1.9 75 3.8 3 No None LVAD No 68 11 0 89 9 25 5 1.3 121 3.5 3 Yes None LVAD No 23 7 0 30 10 593 42 2.1 287 2.3 3 Yes None BiVAD No 0 24 27 51 11 183 39 1.7 45 4.3 3 No IABP LVAD No 15 3 20 38 12 31 21 1.0 79 3.5 3 Yes None LVAD No 7 8 45 60 13 19 20 1.0 35 2.0 4 Yes IABP BiVAD No 9 18 0 27 14 2014 2126 3.5 21 1.6 4 Yes IABP BiVAD No 3 21 0 24 15 30 33 2.0 17 1.0 2 No None LVAD No 2 10 9 21 16 101 540 2.6 160 3.4 4 Yes None LVAD Yes 7 7 6 20 17 107 ··· 0.5 18 1.3 3 Yes IABP BiVAD Yes 0 14 17 31 18 127 202 3.2 40 1.2 4 Yes None BiVAD Yes 9 2 2 13 19 45 110 0.3 22 1.0 2 Yes None LVAD Yes 11 4 61 76

BiVAD = biventricular assist device; CPB = cardiopulmonary bypass;LVAD = left ventricular assist device; OHT = orthotopic heart transplant.

BSA = body surface area; DCM = dilated cardiomyopathy;ICM = ischemic cardiomyopathy; MI = myocardial infarction;PPCM = postpartum cardiomyopathy.

ALT = alanine transaminase; AST = aspartate transaminase; BiVAD = biventricular assist device; BUN = blood urea nitrogen; CPB = cardiopulmonary bypass; ECMO = extracorporeal membrane oxygenation; IABP = intraaortic balloon pump; LVAD = left ventricular assist device; OHT = orthotopic heart transplant.

	References

Top Abstract Introduction Material and methods Results Comment Appendix A Appendix B References

 

1. Allen M.D., Fishbein D.P., McBride M., Ellison M., Daily O.P. Who gets a heart? Rationing and rationalizing in heart transplantation. West J Med 1997;166:326-336.[Medline]
2. Goldstein D.J., Oz M.C., Rose E.A. Implantable left ventricular assist devices. N Engl J Med 1998;339:1522-1533.[Free Full Text]
3. McCarthy P.M., Smedira N.O., Vargo R.L., et al. One hundred patients with the Heartmate left ventricular assist device. J Thorac Cardiovasc Surg 1998;115:904-912.[Abstract/Free Full Text]
4. Sun D.C., Catanese K.A., Spanier T.B., et al. 100 long-term implantable left ventricular assist devices. The Columbia Presbyterian interim experience. Ann Thorac Surg 1999;68:688-694.[Abstract/Free Full Text]
5. Jett G.K. Abiomed BVS 5000i. Ann Thorac Surg 1996;61:301-304.[Abstract/Free Full Text]
6. Champsaur G., Ninet J., Vigneron M., Cochet P., Neidecker J., Boissonnant P. Use of the Abiomed BVS System 5000i as a bridge to cardiac transplantation. J Thorac Cardiovasc Surg 1990;100:122-128.[Abstract]
7. United Network for Organ Sharing. Available at: http//www.unos.org.
8. De Rose J.J., Jr, Umana J.P., Argenziano M., et al. Implantable left ventricular assist devices provide an excellent outpatient bridge to transplantation and recovery. J Am Coll Cardiol 1997;30:1773-1777.[Abstract]
9. Marelli D., Laks H., Amsel B., et al. Temporary mechanical support with the BVS 5000i assist device during treatment of acute myocarditis. J Card Surg 1997;12:55-59.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hillel Laks Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Marelli, D. Articles by Moriguchi, J. D. Search for Related Content PubMed PubMed Citation Articles by Marelli, D. Articles by Moriguchi, J. D. Related Collections Related Article