Surgery for Acquired Cardiovascular Disease Initial experience with the AbioCor Implantable Replacement Heart System

OBJECTIVE We sought to evaluate the safety and efficacy of the first available totally implantable replacement heart (AbioCor Implantable Replacement Heart System) in the treatment of severe, irreversible biventricular heart failure in human patients. METHODS Seven male adult patients with severe, irreversible biventricular failure (>70% thirty-day predicted mortality) who were not candidates for transplantation met all institutional review board study criteria and had placement of the AbioCor Implantable Replacement Heart. All were in cardiogenic shock despite maximal medical therapy, including inotropes and intra-aortic balloon pumps. Mean age was 66.7 +/- 10.4 years (range, 51-79 years). Four of 7 patients had prior operations. Six had ischemic and one had idiopathic cardiomyopathy. All had 3-dimensional computer-simulated implantation of the thoracic unit that predicted adequate fit. At the time of the operation, the internal transcutaneous energy transfer coil, battery, and controller were placed. Biventriculectomy was then performed, and the thoracic unit was placed in an orthotopic position and attached to the atrial cuffs and outflow conduits with quick-connects. The flow was adjusted to 4 to 8 L/min. Central venous and left atrial pressures were maintained at 5 to 15 mm Hg. The device is powered through transcutaneous energy transfer. An atrial flow-balancing chamber is used to adjust left/right balance. The balance chamber and transcutaneous energy transfer eliminate the need for percutaneous lines. RESULTS There was one intraoperative death caused by coagulopathic bleeding and one early death caused by an aprotinin reaction. There have been multiple morbidities primarily related to preexisting illness severity: 5 patients had prolonged intubation, 2 had hepatic failure (resolved in 1), 4 had renal failure (resolved in 3), and 1 each had recurrent gastrointestinal bleeding, acute cholecystitis requiring laparotomy, respiratory failure that resolved after 3 days of extracorporeal membrane oxygenation, and malignant hyperthermia (resolved). There were 3 late deaths: one caused by multiple systems organ failure (postoperative day 56), one caused by a cerebrovascular accident (postoperative day 142), and one caused by retroperitoneal bleeding and resultant multiple systems organ failure (postoperative day 151). This latter patient was not able to tolerate anticoagulation (no anticoagulation or antiplatelet therapy alone for 80% of the first 60 days) and had a transient ischemic attack on postoperative day 61 and a cerebrovascular accident on postoperative day 130. At autopsy, blood pumps were clean. The 2 patients who had large cerebrovascular accidents had thrombus on the atrial cage struts. These struts have been removed for future implants. There has been no significant hemolysis or device-related infections. The balance chamber has allowed for left/right balance in all patients (left atrial pressure within 5 mm Hg of right atrial pressure). Three patients have taken multiple (>50) trips out of the hospital, and 2 have been discharged from the hospital. Total days on support with the AbioCor are 759. CONCLUSION The initial clinical experience suggests that the AbioCor might be effective therapy in patients with advanced biventricular failure. There have been no significant device malfunctions. Two of these patients have been discharged from the hospital.