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Cardiac Surgery and Transplantation 309

TABLE 12.3 Intra-aortic balloon pump alarm states

Alarm state Causes/significance
Catheter alarm ● Obstruction (complete or subtotal) of the catheter, drive line or balloon
● Device reverts to standby (non-assist); commonly due to catheter flexion at insertion site due to limb position
or excessive surface to vessel depth
Loss of trigger ● ECG trigger: signal disrupted or low in amplitude, or asystole
● Pressure trigger: pulse pressure below threshold for detection
● Pacer trigger: pacing spikes not detected or absent (including demand pacing)
● Device reverts to standby until restoration of trigger; alternative trigger selection may be necessary
Gas loss alarms ● Leak in circuit/drive line or balloon; gas leak may be to the environment or into the patient as
a helium embolus
● Pump reverts to standby; refilling of circuit may be necessary
Low augmentation ● Augmented diastolic pressure is lower than operator-selected alarm level; pumping is not interrupted
Pneumatic drive ● Functional problem with the pump inflation/deflation pneumatic system
● Device reverts to standby; alarm may sometimes be activated during tachycardia; 1 : 2 assist or assist at reduced
augmentation may be possible until a replacement device is accessed
Autofill failure ● Routine 2-hourly refilling of the system with helium may fail if gas tank is incompletely open or if circuit leaks
cause volume loss during the filling attempt
● Device reverts to standby
System failure ● Console self-testing has identified component malfunction
● Device reverts to standby; restarting may be possible but a replacement device should be accessed
Low helium supply ● Helium tank empty or incompletely opened
Low battery ● Reconnect to power and recharge

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in December 1967. However, high mortality rates asso- management of patients and their carers. Advances in
ciated with severe acute rejection and infection within device design and capability, e.g. fully implantable with
months of surgery led to a reduction in the number of internal batteries, are likely to be required for this option
heart transplants performed worldwide, and in effect a to be truly viable.
moratorium occurred with the procedure. Heart trans-
plantation was finally established in the modern era as a
viable treatment option for end-stage heart failure during OUTCOMES FROM HEART TRANSPLANTATION
the early 1980s when cyclosporin A, a then-novel immu- Currently, the top centres around the world achieve
nosuppressive agent, dramatically improved patients’ sur- survival rates for heart transplant patients approaching
vival rates by reducing episodes of acute rejection and 80–90% at one year, with more than 50% of patients
lowering attendant infectious complications. 57 surviving longer than 11 years. In Australia and
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New Zealand, approximately 85% of heart transplant
INCIDENCE patients survive to 1 year and 75–80% survive more
62,63
Heart transplants in the modern era have been performed than 5 years.
in Australia since 1986 and in New Zealand since 1987.
In 2009, 72 heart transplants were performed in Australia
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and New Zealand. As the annual number of transplants INDICATIONS
globally is likely to remain relatively stable because of The vast majority of patients referred for heart transplan-
limited organ availability, future routine management of tation have NYHA functional class III or IV symptoms
end-stage heart failure may involve the insertion of a left (see Chapter 10), secondary to ischaemic heart disease or
ventricular assist device (LVAD) designed for long-term some form of dilated cardiomyopathy. 64,65 Commonly,
permanent mechanical circulatory support, so-called patients listed for transplantation have a life expectancy
‘destination therapy’. Indeed, there have been clinical of less than 2 years without transplantation. Accepted
trials that include destination therapy since the success of contraindications for heart transplantation include active
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67
68
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LVADs in the REMATCH study. In the past decade, malignancy, complicated diabetes, morbid obesity,
LVADs available have been used primarily as ‘bridge to uncontrolled infection, active substance abuse and an
transplantation’ therapy (i.e. support for a failing native inability to comply with complex medical regimens. 69,70
heart until a suitable heart becomes available), not ‘des- Age has become a relative contraindication, with 16 days
tination therapy’. The implementation of destination old being the youngest and 71 years of age being the
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therapy will require nurses to gain skills in the long-term oldest. However, the presence of multiple comorbidities