專題討論8:體外生命維持系統在嚴重心臟衰竭的運用與展望

S8-2
短期心室輔助器(CentriMag)在心臟衰竭的使用與展望
蔡峰鈞
林口長庚醫院心臟外科

  Though transplant is golden therapy for terminal heart failure, scarcity of donor and uncertainty of waiting time, make it unavailable to every potential candidate. Ventricular assist device (VAD) is an emerging and attractive alternative but the lack of reimbursement makes it unpopular in Taiwan. Extra corporeal membrane oxygenation (ECMO), on the contrary, is covered by public insurance and advantage of rapid deployment makes it the first choice of cardiogenic shock. Unfortunately, prolonged use over two weeks will often inevitably face some serious complications.
  CentriMag, a short term mechanical cardiac support device, with merits of complete unloading left ventricle, possibility of weaning off ventilator and allowing patient ambulation, fills the gap between the ECMO and VAD. Though inheriting the same extra corporeal centrifugal pump as ECMO, the CE mark of 30 days safety profile provides it as a valuable tool for bridging to transplant. Furthermore, after the cost was reimbursed and pre-application process was waived, not only bridging to transplant but also adjunct to LVAD for right ventricular support gets more popular in Taiwan.
  In real world, heart failure patients are not the same, such as transplant waiting list with acute deterioration, acute fulminant myocarditis or postcardiotomy myocardial stunning. One needs to focus not only the pathology but also the timing of intervention because CentriMag implant is a really invasive open heart procedure and the second operation, either transplant or device explant will be expected. Furthermore, combined right ventricular support is often necessary and may make postoperative care more demanding. The key to success after CentriMag deployment relies strongly on three “R” of right patient, right device and right time. How to apply these concepts will be addressed and one clinical scenario will be raised.
  In conclusion, terminal heart failure treatment has limited options. Reality of donor plateau for transplant and sensitive cost issue of VAD will make both not the first choice for acute cardiogenic shock. Only familiar with CentriMag indications of bridging to transplant from ECMO, adjunct use for right ventricular support in LVAD and bridging to decision or recovery in rare occasions will improve this tragic situation outcome.