Third generation rotary blood pumps (RBP) are designed for permanent implantation and aim to reduce some complications often associated with MCS. Thrombembolic events are one major complication. Consequently an aggressive anticoagulation (AC) and antiplatelet therapy has been applied in the past. This resulted in some cases of fatal hemorrhagic stroke. Moreover, older patients (pts) are more likely to sustain a stroke. We apply only a moderate AC protocol to manage RBP. Data analysis in this study was done with regard to thrombembolic complications in association with the AC therapy.

Die MARS-Lebertherapie (Molecular Adsorbent Recirculating System) konnte zeigen, dass das Überleben von Patienten mit einer akuten Dekompensation einer chronischen Lebererkrankung durch den Einsatz der Therapie verlängert wird. MARS ist eine extrakorporale Behandlung, bei der als Dialysat Humanalbumin verwendet wird und die so albumingebundene Substanzen aus dem Blut entfernen kann. Das Albumin wird über in einem geschlossenen Kreislauf über Aktivkohle- und Anionenadsorber geleitet und so für eine kontinuierliche Behandlung gereinigt.

Aims: The CorAide™, an electrically powered, magnetically levitated third generation LVAS, is designed for long-term mechanical circulatory support (MCS). We started to implant the CorAide in 5/2004. We report our experience with this novel, non-pulsatile system.

Purpose: Advances in LVAD technology have led to newer, miniaturized axial flow pumps. They have proven to be very reliable; due to fewer moving parts compared to pulsatile devices it is expected that they have a longer longevity. We wanted to find out if there are differences in out-of-hospital (OOH) MCS patients (pts) between pulsatile and non-pulsatile devices with special regard to quality of life (QOL).

Objectives: The CentriMag (CM) pump is a magnetically levitated paracorporeal centrifugal pump. The pump is constructed without bearings and rotating seals and therefore reduces shear stress and minimizes the risk of hemolysis and thrombosis.

Objectives: The CorAide™ is an electrically powered, magnetically levitated third generation left ventricular assist system (LVAS), designed for long-term mechanical circulatory support (MCS). We report our initial experience with the CorAide.

Objectives: Some patients (pts) undergoing cardiac surgery may need intra-aortic balloon counterpulsation (IABP). Their outcome is critical with mortality rates of 40%–80%. We performed a retrospective study on 140 pts, requiring IABP after cardiac surgery in our center with the aim to identify predictors of survival.

Objectives: Application of mechanical circulatory support systems (MCS) for treatment of end-stage cardiac failure or cardiogenic shock is gaining more importance. However, the technology is still expensive and its use is associated with high morbidity and mortality. Identification of risk factors might be helpful in optimizing patient selection and outcome.

Thank you for your comments concerning our article. In this first interim analysis of our study, we did not claim that the survival benefit of the Molecular Adsorbent Recirculating System (MARS) group was statistically significant. Nonetheless, an improvement in survival was shown in this patient cohort of the most critically ill patients that one may find in cardiothoracic surgery. Despite the use of mechanical circulatory support, these patients have mortality rates of usually up to 80% after persistent cardiogenic shock.1 To improve survival in these patients is an extremely difficult task. The better survival rate in the MARS group is raising hope and certainly has clinical significance. The study end-point was survival to hospital discharge, which usually was beyond 30 days. As clearly expressed in the Study Methods section, sepsis was an exclusion criteria for our study. Why MARS, though, should not be used, or even the role of it assessed for this patient cohort remains unclear from the reasoning of Drs. O’Beirne and Auzinger. The cardiac performance was comparable at the time of enrollment in both groups and afterwards treated according to necessity. Whether and to which extent continuous veno-venous hemofiltration (CVVH) can clear cytokines is, to our knowledge, disputable. The in vivo study by Kellum et al. cited by our critical readers could only demonstrate a reduction in tumor necrosis factor (TNF)-α and not of any other cytokines; moreover, the study was performed upon septic patients in whom the levels of cytokines might be different from our patients. It is, on the other hand, an accepted fact that MARS therapy does eliminate cytokines. Within the interim analysis, six of the non-MARS group patients were cross-over patients. The total study included 20 patients in each group, with a total of 9 cross-over patients. The overall MARS frequency was 10.5 times per patient and, thus, indeed similar in both groups (8.6 times for the non-MARS group compared with 8.2 times for the MARS group). The untreated patients in the non-MARS group died during the first 48 hours after study inclusion (because of multiple organ failure). The complete study analysis showed, within the surviving group, an average MARS frequency of 4.8 times. Patients requiring more than 14 settings of MARS therapy all died. This supports our initial results that MARS should be used early, and as this became obvious fairly soon in our study, it was the reason for allowing a cross-over group. The increase in bleeding episodes that might be related with MARS therapy and were described by other investigators are more or less observational findings in studies including a very small number of patients, and again their patient cohorts were essentially different from ours. Doria et al.2 performed a study on 10 patients with cirrhosis and described several observations from which they assume that MARS caused a coagulopathy. We did not perform thromboelastogram (TEG) examinations on all of our patients included in the MARS study, but we regularly apply this method now for our mechanical circulatory support patients. Up to now, in case these patients undergo MARS therapy again, we have not observed a relationship between MARS and a worsening of the TEG, but we are certainly keen to verify this in a further MARS study. Hartl et al. applied MARS to five postsurgical patients, of whom two had primary liver disease, two others had pancreatic carcinoma, and the last one had persistent biliary leak and cholangitis. All patients were only included in the study if they presented septic multiple organ dysfunction. Again, we would not apply MARS in septic patients, and we do not think that the patient cohorts are comparable. In our patients, no bleeding complications occurred and no coagulopathy developed. Maybe our primarily cardiac patients do react differently than those with primary liver or abdominal disease. Nevertheless, we still think that there is a chance for selected patients to benefit from MARS therapy. All nonevidence based therapies need to be applied with caution and respect but should be given a chance to become evidence based. Aly El-Banayosy Dagmar Cobaugh Department of Cardiothoracic Surgery, Heart Center NRW, Ruhr University Bochum, Georgstrasse, Oeynhausen, Germany.

Aims: Survival rates of postcardiotomy cardiogenic shock (CS) patients (pts) requiring mechanical circulatory support systems (MCSS) is still poor. This work reports our experience with postcardiotomy CS pts, requiring ECMO or at least three inotropes. Subsequent cardiac replacement with CardioWest-SynCardia (CW) Total Artificial Heart (TAH) was indicated due to prolonged biventricular failure.

Background. Severe, persistent cardiogenic shock is associated with very high morbidity and lethality. We therefore tried to improve the outcome of these patients using a network between local hospitals and a specialized heart center that has facilities for transplantation and ventricular assist device (VAD) implantation.Methods. Between 1998 and 2000, 50 patients, who were in cardiogenic shock (mean age 49 years, SD 14) despite high doses of at least three inotropic agents, were admitted to our specialized heart center. During the first 12 hours, we tried to stabilize the patient's condition, to reduce inotropic support agents, and to keep cardiac index above 2.4 L(.)min(-1.)m(-2). According to this strategy, patients were allocated to medical treatment only, emergency VAD therapy, urgent VAD implantation, or heart transplantation. To assess variables potentially influencing patients' outcome, we performed univariate and multivariate analyses.Results. Early in-hospital mortality was 36% and late mortality was 10%. Overall survival at 1, 6, and 12 months of follow-up was 70%, 56%, and 52%, respectively. Even when the heart transplant patients were excluded, overall 12-months survival after cardiogenic shock was still 50%. Higher age, and the absence of sinus rhythm were the only independent risk factors for 12-month mortality.Conclusions. Our data show that a network between cardiology departments of local hospitals and specialized heart centers can be life-saving for severe, persistent cardiogenic shock patients.

Purpose: Long-term mechanical circulatory support (MCS) is gaining more importance, not only as a bridge to transplantation (BTT), but also as destination therapy (ATT). Discharging patients (pts) home improves quality of life. To prove the safety and efficacy of this ambulatory therapy we analyzed data from 105 OOH pts. Methods: Since 1994, 105 inotrope-dependent pts (12 female, 93 male, aged 12–73 years, mean 511, requiring MCS, fulfilled our discharge criteria for OOH treatment. In an ongoing process we analyze causes of readmissions and complications. Devices applied were Novacor LVAD (n = 60), HeartMate LVAD (n=28), Thoratec assist device (n = 12), LionHeart (n = 3) and recently the CardioWest TAH combined with the BerlinHeart Excor driver (n = 2). Intention to treat was BTT in 89 cases, bridge to recovery in 6 and ATT in 10 cases. Results: Mean OOH support was 202 ±217 days (variation 2–1043 days),equal to a cumulative experience of 54.8 pt years. We counted 87 readmissions in 61 pts (readmission rate of 1.8 per payear). At 229 days 50% of the pts were free from readmission. 38 pts were readmitted l×, 17 pts 2×, 2 pts 3 × and in 4 pts we counted ≤ 4 readmissions. Main causes for readmission were neurological disorders (34%) and infections (24%). Conclusion: The readmission rate of 1.8 per payear is acceptable and better than the readmission rate for pts with terminal heart failure on optimal medical therapy. Our results demonstrate the safety and efficacy of the OOH treatment and justify its use in MCS pts suffering from end-stage heart failure.

The Molecular Adsorbent Recirculating System (MARS) has been proven to prolong survival in patients with hepatorenal syndrome. MARS is a modified dialysis that uses an albumin containing dialysate, which is recirculated and perfused online through charcoal and anion exchanger columns. It allows the selective removal of albumin bound substances.Despite advances in medical therapy and technology, the prognosis of patients with cardiogenic shock remains poor. Mortality rates are as high as 80%, often because of persistent multiple organ failure. To determine whether patients with hypoxic liver failure after cardiogenic shock after cardiac surgery might benefit from MARS, we performed a prospective, randomized, controlled, single center study. The primary objective was to prove that MARS improves survival.This article is a report on the interim analysis of the first 27 patients included between August 2000 and December 2001; 14 patients were in the MARS group, and 13 patients were in the non-MARS group. All had bilirubin levels greater than 8 mg/ml. Both groups had a similar risk profile. The MARS group received MARS for 3 consecutive days—if bilirubin was still greater than 6 mg/dl afterward, MARS was continued. The non-MARS group received conventional therapy.We had seven survivors in the MARS group (50%) compared with four (32%; p = ns) in the non-MARS group. We conclude that despite the limited number of patients included in this analysis, MARS can be recommended for patients with acute, hypoxic liver failure because it might prolong survival. Further studies in similar patient cohorts are needed to verify our results.