Developing a comprehensive mechanical support program.

As cardiac surgery centers appreciate that ventricular assist devices (VAD) can dramatically impact patient survival as a bridge to transplant or recovery, and possibly permanent therapy, increasing numbers will desire to establish mechanical support programs. A number of vital elements must be put in place in order to operate a successful mechanical support program. Of utmost importance is the assembly of a dedicated team focused on comprehensive care of critically ill patients in need of circulatory support. An ongoing commitment from anesthesiologists, cardiologists, nephrologists, and other support staff is essential. Selection of complementary assist devices should be made to cover the spectrum of required support scenarios, both short- and long-term. Outpatient therapy has become increasingly important in mechanical cardiac assistance and establishment of an office where "LVAD coordinators" see outpatients facilitates this aspect of the program. Critically ill patients in need of cardiac assistance may benefit from specialized medical therapies such as: (1) intravenous arginine vasopressin for vasodilatory hypotension; (2) inhaled nitric oxide for right heart failure; (3) aprotinin to reduce hemorrhage; and (4) early enteral feeding in an effort to reduce infectious complications and improve rehabilitation following VAD implantation. A regional network with spoke hospitals centered around a hub hospital with long-term VAD and heart transplant programs can improve survival of patients with postcardiotomy cardiogenic shock via early transfer to the hub hospital. In this article, we describe the components of our mechanical support program that have allowed us to successfully support patients with heart failure in need of circulatory support.