Working heart model of heterotopic heart-lung transplantation in rats.

A technique for a working heart model of heterotopic heart-lung transplantation is described. The donor aorta and left pulmonary artery are anastomosed to the recipient's abdominal aorta in an end-to-side fashion. Arterial blood from the recipient's abdominal aorta enters the donor left heart via the donor left lung and is ejected into the donor ascending aorta by the transplanted left ventricle. With this model, the donor left ventricle performs work comparable to that of the native heart without hypoxia. This model is easily reproducible and can be applied to various studies, including long-term assessments of cardiac remodeling, long-term efficacy of cardiac preservation, and posttransplantation ventricular performance under more physiologic conditions.

Implantation technique for the Novacor left ventricular assist system.

The Novacor left ventricular assist system (Baxter Healthcare Corp., Novacor Div., Oakland, Calif.) is currently undergoing clinical investigation as a bridge to cardiac transplantation. The original animal and clinical protocols recommended placement of the pump/energy converter within the peritoneal space. During preclinical cadaver fitting trials, we determined that it might be difficult to place this device in the peritoneal cavity of tall, slender patients, patients having a small muscular abdomen, and many women. We were also concerned that peritoneal placement would increase the risk and severity of infection and that abdominal organs might be injured by direct contact with the pump. In studies in cadavers, we therefore developed a technique using preperitoneal placement of the pump/energy converter. This technique has now been used successfully in more than 200 patients. A detailed description of this insertion technique is presented to facilitate its current use for the implantation of temporary devices and to plan for the implantation of permanent systems.

Eight years' experience with bridging to cardiac transplantation.

Although bridging to cardiac transplantation has become a therapeutic option for transplant candidates whose condition deteriorates while they are awaiting a donor heart, short-term efficacy has not been proved and long-term survival has not been reported. We retrospectively reviewed data on 44 patients who had circulatory assist devices placed as a bridge to transplantation between May 1985 and April 1993. The 35 male and nine female patients ranged in age from 12 to 65 years (mean 43.8 years). Thirty-one patients were supported with 32 Thoratec (18 left ventricular, 14 biventricular), 11 Novacor, and two Jarvik J-7-70 devices. The duration of device support was from 4 hours to 440 days (mean 45.5 days). Fifteen patients did not receive a donor organ because of infection (ten patients), renal failure (five patients), bleeding (nine patients), cerebrovascular accident (three patients), ventricular fibrillation (one patient), and right heart failure (one patient), and all died. Two patients were weaned from support and survived without transplantation. Twenty-seven patients underwent transplantation, and 26 survived (96%). Overall survival was 64% (28/44). Duration of survival ranged from 2 to 96 months (mean 35 months). Among the 28 hospital survivors, there were four late deaths (all transplant recipients) at 3, 6, 14, and 68 months. Posttransplantation actuarial survivals at 1, 5, and 8 years are 88%, 83%, and 66%. Twenty-three of the 24 patients presently alive are in New York Heart Association functional class I. These data demonstrate the short- and long-term efficacy of bridging to transplantation with circulatory support devices. The excellent survival and full functional recovery of patients undergoing transplantation ensure that donor organs are not being "wasted" on the sickest patients.

Transfer of patients receiving advanced mechanical circulatory support.

OBJECTIVE: Improving results with ventricular assist devices have led to their wider clinical application. Centers can stabilize, support, and wean or transfer patients to regional transplant centers. METHODS: Prospectively collected data were reviewed to evaluate the clinical results of patients transferred to our institution while receiving advanced mechanical circulatory support. RESULTS: Since 1993, 16 patients were accepted while receiving support with either extracorporeal membrane oxygenation or a ventricular assist device. The 10 male and 6 female patients ranged in age from 9 to 60 years (mean, 42.1 years). Thirteen had had cardiac surgical procedures, two had acute myocardial infarctions, and one had myocarditis. The distance transported ranged from 0.2 to 309 miles (mean, 132 miles). Twelve patients were transferred by ground, and 4 were transported by air. Seven patients were originally supported with extracorporeal membrane oxygenation, 6 with centrifugal pumps, and 3 with ABIOMED ventricular assist devices (ABIOMED, Inc, Danvers, Mass). Two patients had clinical complications during transfer, and one had a cerebrovascular accident, recovered, was weaned, and survived. A second patient had hemodynamic deterioration. There were no technical complications associated with transport. Six patients were left on the original support device; 3 of the 6 were weaned and survived, and 3 died during support. The 10 remaining patients were switched to other ventricular assist devices: 9 patients to Thoratec devices (Thoratec Laboratories, Pleasanton, Calif) and 1 patient to a Novacor device (Baxter Healthcare Corp, Novacor Division, Oakland, Calif). Six of the 10 patients underwent transplantation and survived. Four patients died while being supported by the devices. Nine patients were discharged, with 1 late death at 29 months. Eight patients are alive 4 to 65 months after discharge. CONCLUSIONS: These data suggest that patients receiving advanced support can be moved between clinical centers with acceptable risks. Because 33% of the survivors were weaned, transplantation is not required for survival.

Follow-up of survivors of mechanical circulatory support.

Improvements in mechanical support for profound circulatory collapse have resulted in increasing survival of these critically ill patients. Since 1980, 27 patients aged 3 days to 69 years (mean 34.9 years) who required mechanical circulatory assistance have been followed up after discharge from the hospital. The refractory cardiogenic shock necessitating mechanical support occurred postoperatively in 22 patients (coronary artery bypass in nine, valve replacement in four, correction of congenital heart defects in nine) and with end-stage cardiomyopathy in five. Fourteen patients were supported with a Pierce-Donachy ventricular assist device (left ventricular assist in seven, right ventricular assist in three, both in four); nine were supported with extracorporeal membrane oxygenation, two with a Medtronic centrifugal left ventricular assist pump, one with biventricular Biomedicus pumps, and one with a Novacor left ventricular assist system. The duration of support ranged from 8 hours to 91 days with a mean of 3.5 days in patients supported for postoperative shock. Major complications occurred in 18 patients (67%), including bleeding that necessitated operative exploration in 14, serious infection in five, renal failure in two, and stroke in two. The five patients with cardiomyopathy underwent cardiac transplantation. The remaining 22 patients who had postoperative cardiogenic shock were weaned from support. There have been four late deaths: two cardiac related at 6 months and two of cancer at 46 and 53 months (one patient was in New York Heart Association class I and the other in class II before death). The remaining 23 survivors have been followed up for 3 to 79 months (mean 29 months) and at last examination 17 (74%) were in class I, two (9%) were in class II, three (13%) were in class III, and one (4%) was in class IV. Eight patients are employed full time, three are retired, four attend school, three are in preschool, one is a housewife, and one is unemployed but free of symptoms. Only four patients have significant cardiac disability, and one of these still works. In conclusion, mechanical circulatory assistance allows adequate support to permit satisfactory long-term survival in patients with refractory cardiogenic shock.

Intraaortic balloon pumping in patients requiring cardiac operations. Risk analysis and long-term follow-up.

The intraaortic balloon pump is usually the first mechanical device inserted for perioperative cardiac failure; however, little current information is available regarding short- and long-term effectiveness. From January 1983 through November 1990, 6856 adult patients underwent cardiac surgical procedures, 580 of whom (8.5%) had an intraaortic balloon inserted preoperatively (107 patients), intraoperatively (419 patients), or postoperatively (54 patients). There were 374 men and 206 women with a mean age of 63.9 years (range 19 to 88). Operations included 376 coronary artery bypass grafts, 100 mitral valve replacements (with or without bypass grafting), 70 aortic valve replacements (with or without bypass grafting), 15 double valve replacements (with or without bypass grafting), and 32 other procedures. There were 72 (12.4%) complications related to the balloon pump, of which 42 necessitated surgical intervention including thrombectomy (21), vascular repair (13), fasciotomy (2), aortic repair (1), and amputation (4). Operative mortality for patients supported by the balloon pump was 44%. Multivariate stepwise analysis of 27 parameters revealed six independent predictors of mortality: preoperative New York Heart Association class, transthoracic intraaortic balloon insertion (both p < 0.0001), preoperative administration of intravenous nitroglycerin, age, female gender, and preoperative balloon insertion (p < 0.001). Balloon-related complications were not predictive of death. Of the 326 hospital survivors, only 34 were lost to follow-up. There were 75 late deaths, the cause of which was cardiac in 41 (55%), noncardiac in 20 (27%), and unknown in 14 (19%). Actuarial survivals at 1, 5, and 9 years are 51%, 42%, and 33%. Of the 217 hospital survivors still alive and contacted, 81% were in class I (114) or II (60). These data demonstrate (1) operative mortality for patients requiring an intraaortic balloon in the perioperative period remains high, (2) perioperative risk factors can be identified, (3) complications related to the balloon pump do not affect survival, (4) operative survivors can achieve prolonged survival with excellent functional results, and (5) consideration for alternative methods of circulatory support is justified.

Asymmetric intramyocardial lymphocytic accumulation during acute rejection in rat heart and heart-lung transplantation.

Lymphocytic accumulation in different areas of the myocardium during different phases of acute rejection were studied in rat heterotopic cardiac and cardiopulmonary allograft and isograft transplantation models. Indium 111-labeled syngeneic lymphocytes were injected 1 to 7 days after transplantation, and accumulation of the labeled cells in the graft was determined 24 hours later. The cardiac graft was divided into three segments: right ventricular (RV) free wall, epicardial portion of the left ventricle (LV) plus RV septum, and endocardial portion of the LV. In the subsequent heart-lung transplantation group, the LV epicardial portion plus RV septum segment was subdivided into LV epicardial portion and RV septum. Lymphocytic accumulation in each segment was compared between three groups according to the day the animal was killed after transplantation: days 2, 3 (group 1), days 4, 5 (group 2), and days 6, 7, 8 (group 3). Lymphocytic accumulation caused by rejection in group 1 and group 2 of both the cardiac and cardiopulmonary allografts showed significantly different intramyocardial distribution (p less than 0.01). Lymphocytic accumulation was consistently highest in RV free wall and lowest in LV endocardial portion. In group 3 specimens, lymphocytic accumulation was symmetrical in both the cardiac and cardiopulmonary allografts. In the cardiac allograft, the lymphocytic accumulation increased sharply on day 4 then declined to a nadir. This transient increase was not so pronounced in the cardiopulmonary allografts. The significantly decreased intramyocardial lymphocytic accumulation in group 2 of the cardiopulmonary allografts when compared with the cardiac allografts (p less than 0.01) is compatible with the clinical observation of a lower incidence of acute heart rejection in heart-lung transplant recipients. These data show an asymmetric accumulation of lymphocytes during acute heart rejection, which is due to increased lymphocytic affinity for the RV free wall.

Eleven years' experience with the Pierce-Donachy ventricular assist device.

During the last decade, mechanical circulatory support has been used in patients with cardiogenic shock refractory to conventional therapy. Since 1982, we supported 77 patients (78 implants) with Pierce-Donachy external pneumatic ventricular assist devices. Forty-two patients (35 after cardiotomy, four after heart transplantation, and three with acute infarction) 15 to 71 years of age (mean age 52 years) were supported for cardiac recovery. Left ventricular assist devices were used in 16 patients, right ventricular assist devices plus intraaortic balloon were used in nine, and biventricular assist devices were used in 17. Patients were supported 0.2 to 17 days (mean 4.4 days), 18 patients (43%) were weaned, and 11 (26%) survived. Complications included acute myocardial infarction (60%), bleeding (48%), infection (38%), and renal failure (24%). Bridging to transplantation was attempted in 35 patients (one patient underwent the procedure twice), 12 to 63 years of age (mean age 40 years). Left ventricular assist devices were used 19 times, and biventricular assist devices were used 17 times. Duration of support was 0.2 to 95 days (mean 24 days). All 20 patients who underwent transplantation were discharged. Of the 15 patients who did not undergo transplantation, two were weaned and survived, whereas the remaining 13 patients (who did not undergo transplantation because of complications) died with the device in place. In the patients in the bridge to transplantation group, bleeding occurred in 26%, infection in 55%, and renal failure in 15%. In the entire group of 77 patients, the incidence of ventricular assist device-related thromboembolism was 6%, but only 4% had neurologic deficits.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart transplantation charges: status 1 versus status 2 patients.

BACKGROUND: The current health care environment mandates closer scrutiny of health care dollar allocation. To better understand the distribution of heart transplantation costs, we reviewed hospital and physician billing of patients who underwent orthotopic heart transplantation between August 1988 and September 1993. METHODS: This study is a retrospective review of 107 consecutive cases. Charges and clinical results of United Network for Organ Sharing status 1 patients (n = 46), including 17 bridge to transplantation patients, were compared with those of United Network for Organ Sharing status 2 patients (n = 57). Charges were converted to 1992 dollars. RESULTS: During the first 12 months of the study, 77% of heart transplantations were performed in United Network for Organ Sharing status 2 patients, whereas over the last 12-month period, 25% of the transplantations were performed in status 2 patients. No significant differences were found in age, gender, type of cardiomyopathy, or survival between the status 1 and status 2 groups. The length of hospitalization for the status 1 group ranged from 8 to 138 days (mean 49 days) as opposed to 5 to 82 days (mean 17.5 days) for the status 2 group (p < 0.0001). Pretransplantation hospital charges were significantly higher for the status 1 group ($47,917 to $341,215, mean $109,116) when compared with status 2 ($0 to $10,035, mean $250) (p < 0.0001). No significant difference was found in posttransplantation hospital charges between status 1 ($47,917 to $210,027, mean $95,379) and status 2 patients ($48,093 to $380,745, mean $102,265). Total charges were significantly higher (p < 0.0001) for the status 1 group ($89,910 to $512,331, mean $239,375) when compared with the status 2 group ($63,885 to $455,680, mean $128,594). Total transplantation charges for the study period were $18,341,108. This amount could have paid for 77 status 1 transplantations or 143 status 2 transplantations. CONCLUSIONS: If current trends continue and the donor pool remains the same, most transplant recipients will be status 1, resulting in a comparable number of transplantations performed at twice the charges.

Univentricular versus biventricular assist device support.

Controversy continues over whether patients should receive selective univentricular assist devices (UVADs) or biventricular assist devices (BVADs). Data from 39 patients supported for more than 2 days with Thoratec VADs were analyzed to compare mortality and morbidity between those receiving UVAD versus BVAD. Twenty-three patients received UVADs and 16 BVADs. Age, gender, and duration of support did not differ significantly between the two groups. Morbidity in VAD patients does not differ between UVAD and BVAD support. Survival is determined by the reversibility of pre-VAD myocardial damage or the eligibility for transplantation, rather than by the number of devices used. These data do not support the use of BVAD in all patients; they support a selective approach based on hemodynamic requirements.

Status I heart transplant patients: conventional versus ventricular assist device support.

Since 1985, 59 United Network for Organ Sharing status I patients have been considered for heart transplantation. Thirty-four patients were supported with drugs and/or intraaortic balloon pump (IABP) (group I). Twenty-five patients were supported with ventricular assist devices (VADs, group II). Forty percent of the patients in each group died before transplantation. Of the 20 group I patients who underwent transplantation, all received inotropic drugs, and five also required IABPs. All 14 group II patients who underwent transplantation were bridged with VADs. No difference was found in age, sex, or cause of disease between the groups. Complications after transplantation were more common in group I. Fourteen group I patients (70%) and 14 group II patients (100%) were discharged from the hospital (p = 0.03). One year after transplantation, mean left ventricular ejection fraction by cardiac catheterization was 53% in group I (12 patients) and 72% in group II (11 patients; p = 0.0008). Although VAD support does not insure transplantation, it strongly favors transplantation survival in status I patients. These data further suggest an advantage of VAD support for long-term survival.

Circulatory support in infants and children.

Although the last decade has brought dramatic improvement in patient selection and postoperative management of adults and children undergoing advanced mechanical circulatory support, technological advances have been largely limited to the adult population. Intraaortic balloon pumps are technically feasible, but their efficacy has been questioned and their use has been limited in children. Over the last decade, extracorporeal membrane oxygenation has become the most commonly used method of mechanical circulatory support in children who have severe cardiac failure after cardiac operations. Additionally, a small number of infants and children have been supported with extracorporeal membrane oxygenation as a bridge to cardiac transplantation or as temporary support during reversible myocardial failure due to lesions such as viral myocarditis. More recently, a small number of pediatric patients have been supported with centrifugal and pneumatic devices, particularly after cardiac operations. Surprisingly, many of these patients did well with left ventricular support only. The overall children's survival rates in the myocardial recovery group are better than those in adults. However, current pediatric devices do not provide support for greater than a few weeks, making bridging to transplantation less feasible than in adults.

Replacement of paracorporeal ventricular assist devices.

In this communication we describe a technique to change paracorporeal ventricular assist devices after the development of mechanical complications. This procedure is technically simple and in our experience does not require a sternotomy or cardiopulmonary bypass. Paracorporeal ventricular assist devices can be safely changed allowing continued support and survival.

Effect of advancing age on cost and outcome of coronary artery bypass grafting.

The clinical and billing records of 250 patients (173 men and 77 women) undergoing isolated coronary artery bypass grafting between 1987 and mid-1990 were retrospectively reviewed to determine charges and clinical results as related to age. Patients were stratified by age into five groups of 50 consecutive patients each: group 1, less than 50 years of age; group 2, 50 to 59 years; group 3, 60 to 69 years; group 4, 70 to 79 years; and group 5, 80 years or older. The groups were compared in regard to perioperative clinical variables, long-term follow-up, and total charges. Group 5 had significantly more postoperative complications than the other four groups (p < 0.05). In addition, length of postoperative hospitalization was significantly longer in group 5 compared with groups 1, 2, and 3 (p < 0.05), and operative mortality in group 5 (20%) was significantly higher than that in the other four groups. The mean total charges for group 5 were $73,399, which was significantly higher than the totals in the other four groups (p < 0.05). Actuarial 3-year survival for the hospital survivors was 87%, 89%, 78%, 82%, and 60% for groups 1, 2, 3, 4, and 5, respectively (p < 0.001). Postoperative performance as measured by the Karnofsky scale was significantly lower in group 5 than in groups 1 and 2 (p < 0.05). These data support the premise that elderly patients undergoing coronary artery bypass grafting have more complications, longer hospitalizations, and higher operative mortality than younger patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular cannula obstruction in a patient with previous ventricular aneurysmectomy.

Cannula position is an important factor influencing optimal ventricular assist device function. A case of inflow cannula malposition resulting in suboptimal left ventricular assist device performance is presented. A discussion of alternative techniques and diagnosis is provided.

Right ventricular infarction during left ventricular assist system support.

Left ventricular assist devices are frequently used to bridge patients to cardiac transplantation. As this experience grows, new and unanticipated complications will occur. This report describes a 50-year-old man with ischemic cardiomyopathy being bridged to cardiac transplantation who suffered an acute right ventricular infarction during the interval of support.

Effect of triiodothyronine on graft function in a model of heart transplantation.

BACKGROUND: Brain death is associated with neuroendocrine changes that result in impaired metabolism, reduced myocardial energy stores, and deteriorating cardiac function. As a result of these changes, a substantial number of normal human hearts are not considered suitable for transplantation. In the hope of preventing these complications and stabilizing the condition of cardiac donors, we compared the function of transplanted hearts from brain-dead rats that received triiodothyronine (T3) (n = 6) with that of hearts from a group that received a placebo (n = 5). METHODS: This experiment was designed to be both blinded and randomized. Brain death was achieved by bilateral carotid ligation and inflation of an intracranial balloon. Triiodothyronine or placebo was administered in a blinded, randomized fashion. The brain-dead donors were then supported with conventional techniques for 2 hours after which time heterotopic transplantation was performed using hypothermic preservation and a working heart model. Hemodynamics of the transplanted hearts were assessed 48 hours postoperatively. RESULTS: The hearts from donors that had been pretreated with T3 were found to have a significantly higher (p < 0.005) peak left ventricular pressure than the hearts from the placebo-treated group (137 +/- 17 mm Hg versus 115 +/- 15 mm Hg). Left ventricular end-diastolic pressure was significantly lower (p < 0.01) in the T3-treated group (5.2 +/- 2.2 mm Hg) compared with the placebo-treated group (6.9 +/- 0.5 mm Hg). There was also a significantly higher (p = 0.03) maximal first derivative of left ventricular pressure in the T3-treated group compared with the placebo-treated group (4,876 +/- 1,348 mm Hg/s versus 3,344 +/- 1,016 mm Hg/s). Finally, the cardiac output in the group given T3 was 93 +/- 16 mL/min compared with 61 +/- 22 mL/min in the group given the placebo (p < 0.01). CONCLUSIONS: Hearts from brain-dead rats that had received T3 before transplantation showed improved postoperative function. The experimental design of predonation brain death, cold immersion storage, and transplantation in a working heart model should make these data more relevant clinically than those previously reported.

Late patency of the internal mammary artery as a coronary bypass conduit.

From January, 1972, through August, 1977, 472 patients had internal mammary artery (IMA) coronary bypass, of which 100 were double-IMA bypasses. We selected those patients having a widely patent IMA one year postoperatively who then had a second catheterization 49 to 105 (mean, 64) months following operation. None of the 93 patients who met these criteria was specifically recalled for this study; they all had follow-up catheterizations for multiple other reasons. All of the 91 left IMA and 22 right IMA bypasses (total, 113) were patent at late catheterization, but 1 right IMA was diffusely narrowed. One left IMA had acute angulation with 50% stenosis proximal to the distal anastomosis, which was unchanged over the follow-up interval. There were 100 patent saphenous vein bypasses at one year and 87 at late catheterization. Late closure of coronary bypass grafts is secondary to progression of coronary disease, atherosclerosis of the bypass conduit, or intimal proliferation. Because we have not encountered the latter two causes of conduit closure, IMA grafts remain our graft of choice for nonemergent operations in patients under 60 years of age having revascularization of the left anterior descending coronary artery system.

Diltiazem as an adjunct to cold blood potassium cardioplegia: a clinical assessment of dose and prospective randomization.

Diltiazem was evaluated as an adjunct to cold blood potassium cardioplegia in 63 patients undergoing elective coronary artery bypass grafting. The dual-phase study compared incrementally increasing doses (50, 100, and 150 micrograms/kg) of diltiazem using a single-blind, randomized schedule with an equivalent volume of placebo added to each of three infusions of cold (10 degrees C +/- 2 degrees C) blood containing potassium chloride at 25 mEq/L for the initial infusion (400 ml) and at 12 mEq/L for the next two infusions (300 ml each). Observations included a number of operative variables, creatine kinase (CK)-MB curves, two-dimensional echocardiography, and pulsed Doppler sonography before operation and on postoperative days 1 and 5. Pulmonary artery thermistor catheter responses were observed for 16 hours postoperatively, as were left ventricular micromanometer-tipped catheter responses in 7 patients. As the dose of diltiazem was increased, there was increasing time to atrioventricular node refunction (23.6 to 62.0 minutes). Diltiazem at 100 micrograms/kg (D-100) resulted in a significantly lower peak CK-MB activity than its placebo. Peak - dp/dt increased in treated patients and decreased in patients given the placebo. The cardiac index in D-100 patients was greater on the first postoperative day than preoperatively. The stroke index returned to the control level by the fifth postoperative day in D-50 and D-100 patients only, and it remained depressed in placebo patients. Although few benefits were realized from the addition of diltiazem to cold blood potassium cardioplegia, there was dose-related prolongation of the atrioventricular node recovery time, which required cardiac pacing and thus was associated with its attendant risks.

Clinical experience with 111 thoratec ventricular assist devices.

BACKGROUND: Ventricular assist devices (VADs) have gained wider acceptance due to refinements in patient selection and management and device availability. METHODS: To evaluate early and late results, we reviewed our first 111 patients with the Thoratec VAD. RESULTS: Forty-four patients were supported for myocardial recovery. The mean age in the recovery group was 51.9 years. There were 18 left VADs (LVADs), 17 biventricular VADs (BVADs), and nine right VADs (RVADs). Complications included bleeding in 20 patients (45%) and device-related infection in 1 patient (2%). Nineteen were weaned from the VAD, with 12 survivors. Sixty-seven patients were supported as a bridge to cardiac transplantation. The mean age was 41.5 years. There were 39 LVADs and 28 BVADs. Complications included bleeding in 21 patients (31%) and device-related infection in 12 (18%). Three patients were weaned and 39 patients were transplanted from the assist device, for a total of 42 bridge survivors. Device-related thromboembolism occurred in 9 patients (8.1%), 7 of whom were bridge to transplantation. The duration of VAD support ranged from 0.1 to 27 days (mean 4.5 days) in the recovery group and 0.2 to 184 days (mean 40.7 days) in the bridge to transplantation group. The 10-year actuarial survival was 16% for the recovery group, 22%, for the bridge group, and 33% for transplanted patients. CONCLUSIONS: Despite advances, VAD support remains associated with significant morbidity and operative mortality.