Bridge to removal: a paradigm shift for left ventricular assist device therapy.

Ventricular assist devices have become standard therapy for patients with advanced heart failure either as a bridge to transplantation or destination therapy. Despite the functional and biologic evidence of reverse cardiac remodeling, few patients actually proceed to myocardial recovery, and even fewer to the point of having their device explanted. An enhanced understanding of the biology and care of the mechanically supported patient has redirected focus on the possibility of using ventricular assist devices as a bridge to myocardial recovery and removal. Herein, we review the current issues and approaches to transforming myocardial recovery to a practical reality.

Baseline red blood cell osmotic fragility does not predict the degree of post-LVAD hemolysis.

Continuous-flow left ventricular assist devices (LVADs) subject elements of the blood to significant stress, resulting in clinically significant and subclinical hemolysis. We sought to prospectively determine whether baseline red-cell osmotic fragility of an advanced heart-failure patient influences the hemolytic response to LVAD support. Osmotic fragility assesses the degree of red-blood-cell hemolysis under varying degrees of osmotic stress. Assays were prospectively obtained on 50 consecutive patients prior to placement of continuous-flow LVADs: HeartMate II (n = 34), Jarvik 2000 (n = 5), HeartWare (n = 6). The mean age of the patients was 60.2 years and 87% were male and 47% were nonischemic. The overall median post-LVAD lactate dehydrogenase (LDH) was 583 (427-965), and there was no difference between devices. Mean hemolysis was 15.68 ± 12.96% at 0.45% NaCl (the inflection point of the osmotic fragility hemolysis curve). A scatter plot did not reveal any relationship between preoperative osmotic fragility and postoperative LDH. Linear regression confirmed no predictive relationship (p = 0.71). In conclusion, preoperative variations in osmotic fragility do not appear to account for differences in hemolysis following ventricular assist device placement. Mechanical forces generated by existing LVADs result in similar levels of biochemical hemolysis, as assessed by LDH, despite baseline differences in a patient's osmotic red-cell fragility.

Successful use of extracorporeal membrane oxygenation for acute respiratory failure in a patient with chronic granulomatous disease.

A 9-year-old boy presented with pneumonia, bilateral pulmonary lesions, and fulminant respiratory failure requiring support with extracorporeal membrane oxygenation (ECMO). Open lung biopsy and subsequent bronchoscopy identified Nocardia cyriacigeorgica and Burkholderia cepacia pneumonia. Chronic granulomatous disease (CGD) was diagnosed by an abnormal neutrophil oxidative burst assay. An aggressive diagnostic and therapeutic strategy, which included ECMO, allowed for patient survival and return to baseline function. No ECMO survivors with CGD have previously been reported. It is now recognized that several forms of CGD exist, and some forms may be compatible with long-term survival. Therefore, the diagnosis of CGD should not necessarily be considered a contraindication to ECMO. This is the first known survivor of CGD-related acute respiratory failure supported by ECMO.