Update on mechanical circulatory support in heart failure

• heart failure
• mechanical support
• left ventricular assist device

Temporary mechanical support technology has advanced, and the miniaturisation of these devices has permitted their use with less operative morbidity and more rapid functional recovery following operation. At present a broad range of devices are available. The most comprehensive mechanical support for both the systemic and the pulmonary circulation is still best provided by extracorporeal membrane oxygenation for extremely ill patients with lung and heart failure, which remains a cumbersome and invasive but extremely effective form of short term mechanical support.^w1 However, the development of devices such as the Impella and the Tandem-Heart has allowed less invasive forms of temporary support of the systemic circulation typically applied during high risk percutaneous intervention procedures, such as high risk coronary stenting^{w2 w3} and cardiogenic shock.^{w4 w5} Larger, external pulsatile pumps such as the AbioMed 5000 and the more recent magnetically levitated centrifugal Centrimag pump are used to provide temporary support of either the left or right ventricle or both as a short term rescue strategy post-cardiotomy, or as a bridge to more long term cardiac replacement treatment or recovery.^w6–w9

Counterpulsation technology remains a mainstay of acute care in patients with cardiogenic shock, both before and after surgical or percutaneous intervention. This technology has been developed and miniaturised for potential long term use in ambulatory patients, most notably the Akpulsor (Cardiak, Ltd, Oxford, UK), C-Pulse (Sunshine Heart Inc, New South Wales, Australia), and CardioPlus (CardioPlus, Inc, Detroit, Michigan, USA) devices. None of these devices has been evaluated in a US Food and Drug Administration (FDA) or European CE approved trial. Finally, enhanced external counterpulsation treatment has been established as an effective therapy in intractable angina in non-revascularisable patients with coronary artery disease. The counterpulsation principle and marked left ventricular afterload reduction may also be helpful in congestive heart failure …