Josh Bristow was in the late stages of heart failure when he came to the Emergency Department at Cedars-Sinai Medical Center on Aug. 25, 2007.
Medications and the earlier implantation of a pacemaker had given him some time, but the 51-year-old Studio City man's heart could no longer supply the blood and oxygen his body needed, and he was running out of options.
Bristow is a long-term survivor of AIDS, which probably led to the deteriorating function of his heart (HIV-associated cardiomyopathy). The immune-compromising nature of the illness virtually excluded him as a candidate for heart transplantation because of the increased risk of infection and the inability to undergo immunosuppression to prevent organ rejection.
But on Aug. 30, in an operation led by Sinan A. Simsir, M.D., surgical director of the Heart Transplant and Ventricular Assist Device Program at Cedars-Sinai's Heart Institute, Bristow became one of a very few patients with AIDS to have a left ventricular assist device (LVAD) implanted as “destination therapy.” His heart remains in place, as does the previously implanted pacemaker, but the LVAD has taken on most of the organ's workload.
Left ventricular assist devices are often used as a “bridge to transplant,” prolonging a patient's survival until a donor heart becomes available. But for certain patients with AIDS, cancer and other conditions that preclude immunosuppressive therapy, an LVAD can now be considered a permanent solution, replacing the function of the left ventricle, the heart's main pumping chamber, to return oxygenated blood into circulation.
“This option has not been considered frequently in patients with HIV or AIDS because of the associated infections, pneumonias and other considerations that are common with the illness. In this case, Mr. Bristow was here at just the right time, when no other infections were going on. I think it was a timing issue as well as a recognition among our team members that this therapy may be possible for him,” said Lawrence Czer, M.D., medical director of the Heart Transplant Program and director of Transplantation Cardiology.
According to cardiologist Ernst R. Schwarz, M.D., Ph.D., members of the LVAD team are making an effort to provide information in community settings on heart failure and treatment options. “Patients and even many physicians are not familiar with left ventricular assist devices. They may think of them as a research tool or a useful device for very special cases, but they are not aware that they may be considered a routine option for an end-stage heart failure patient,” he said.
Only a few hospitals in the nation – maybe about three dozen, estimates Simsir – are approved to offer LVADs for destination therapy. The treatment is generally covered by Medicare, Medicaid and insurance plans for appropriate patients.
The device is placed on top of the stomach, under the muscles of the abdomen. One tube is attached to the heart's left ventricle and another goes to the aorta. Thin electrical cords exit the body through an opening in the skin and connect to an external “fanny pack” of rechargeable batteries, giving the patient the freedom to live at home with few limitations.
“Although the operation is relatively straightforward, there is risk with this or any other surgical procedure,” Simsir said, adding that possible complications include stroke, post-operative bleeding and device malfunction. Risk of infection, especially in patients with compromised immune systems, is one of the greatest concerns.
“Artificial devices do not have the natural defenses of white blood cells and mechanisms in the tissues to prevent infection, which means we have to be meticulous in surgery and post-operatively, with the use of antibiotics and other measures to keep the device from becoming infected,” said Czer. “Judgment is needed in deciding whether to proceed with this therapy. It is not for everyone with HIV or AIDS, but in a selected population, this does offer some hope to patients who would be in an otherwise hopeless situation.”
Schwarz said that because the device is mechanical with electronic components, members of the LVAD team, including coordinators, electrical technicians and sometimes physicians, visit patients' homes to be sure electrical systems are adequate and there is always a power backup. They also teach patients, family members and others the steps to take in an emergency.