391 First CARMAT implantation in Italy: a nurse’s experience

Aims CARMAT is a new fully implantable device that simulates heart function. CARMAT has three characteristics that allow a physiological simulation that is at the top of biomedical engineering: it is blood-compatible for the use of bovine pericardium; it is pulsatile because it has hydraulic pumps that mimic systole and diastole; it is capable of self-regulating with the physiological needs of the patient. CARMAT has four biological valves that allow the intake of cardioaspirin avoiding the use of Coumadin and continuous blood draw. CARMAT also has two hybrid membranes with an internal part formed by bovine pericardium and an external polyurethane membrane; CARMAT has self-regulation sensors that adapt the system to the patient’s efforts. The operation is relatively simple because the rollers placed inside move the silicondressingstely and so it pushes the walls creating systole and diastole not synchronously as it normally happens but asynchronously, one ventricle at a time. Evaluation of the patient’s haemodynamics, monitoring of vital parameters, dressings of the drive-line, and psychological state. Methods and results Training in the field by the manufacturer due to the absence of material in literature. Since it was the first CARMAT implantation in Italy, we tried to combine experience with the clinical practice of other artificial hearts. The patient was weaned from anesthesia early and extubated; the patient did not show neurological damage. Psychologically, the artificial heart was accepted without any problems by the patient, the drive line had no infections, and the patient was discharged quickly. Conclusions The CARMAT system appears to be the one that best simulates the physiology of the heart because it involves fewer complications than other artificial hearts. This device is used as a bridge to transplant, but research and continuous studies tend to transform it as a therapy to end for patients who leave the transplant list and therefore the possibility of having a heart transplant.

Ethical Issues in the Deactivation of Total Artificial Heart Support – A Systematic Review

"Introduction: In the context of a relatively constant heart donation rate, the effort to satisfy the needs, has led to the development of mechanical devices that can replace the cardiac function. Estimating an annual potential of 100,000 artificial heart implants in the United States alone, there is an increased interest in these devices, which is why it is appropriate to explore the situations where its inactivation may be ethically appropriate. Method: We performed a systematic review, which includes all the studies regarding the dilemma of artificial hearts inactivation from the beginning until 2020, published in PubMed, Embase and Scopus. The searched keywords were “totally artificial heart and ethics”; the duplicate studies and those referring to other cardiac support devices were excluded. Results: Following the selection, 12 articles were included in the review. The conflict between the principle of discontinuity and the prohibition generated by the indispensability of the artificial heart was emphasized. The decision to inactivate the support dependent on the patient’s declared level of happiness or clinical evolution over time was reviewed. The dilemma of self-inactivation of artificial cardiac support as suicide versus the acceptance of death caused by the underlying heart condition, as well as the impact of total removal of the native heart were included in the ethical analysis. Conclusions: Requests for withdrawal of TAH support are not uncommon among patients, their discontinuation being ethically acceptable when it does not serve the patient’s interests, even though they may still be capable to prolong their life. "

Michael E. DeBakey: A cardio-vascular surgeon whose innovations revolutionized the treatment of heart and blood vessel

Michael Ellis DeBakey was a Lebanese-American cardiac surgeon and vascular surgeon, scientist and medical educator. After WW II, joined the faculty of Baylor University College of Medicine, serving as chairman of surgical department and hired surgeon Denton A. Cooley and revolutionized the management of cardiac and vascular diseases. His contributions in the development of roller pump for transfusion of blood directly from person to person which later became a component of the heart-lung machine. DeBakey’s surgical innovations included coronary bypass operations, carotid endarterectomy, aortic aneurysm surgery, artificial hearts, ventricular assist devices, vascular grafts (Dacron) saved thousands of lives and made him surgical immortal.

Heartbeats, Burdens, and Biofixtures

This paper addresses a dichotomy in the attitudes of some clinicians and bioethicists regarding whether there is a moral difference between deactivating a cardiac pacemaker in a highly dependent patient at the end of life, as opposed to standard cases of withdrawal of treatment. Although many clinicians hold that there is a difference, some bioethicists maintain that the two sorts of cases are morally equivalent. The author explores one potential morally significant point of difference between pacemakers and certain other life-sustaining treatments: specifically, that the former are biofixtures, which become part of the patient in a way that the latter do not. The concept of the pacemaker as biofixture grants pacemakers a unique moral status that gives reason to treat a pacemaker the same as other parts of the patient that are necessary to sustain life. The author employs this biofixture analysis to affirm the intuition that deactivating a pacemaker in a highly dependent patient at the end of life is, in moral terms, more analogous to active euthanasia than it is to standard cases of withdrawal of treatment. The paper concludes with consideration of potential implications for further implantable medical technologies, such as ventricular assist devices and total artificial hearts.

Be still, my beating heart: reading pulselessness from Shakespeare to the artificial heart

Today, patients with heart failure can be kept alive by an artificial heart while they await a heart transplant. These modern artificial hearts, or left ventricular assist devices (LVADs), remove the patient’s discernible pulse while still maintaining life. This technology contradicts physiological, historical and sociocultural understandings of the pulse as central to human life. In this essay, we consider the ramifications of this contrast between the historical and cultural importance placed on the pulse (especially in relation to our sense of self) and living with a pulseless LVAD. We argue that the pulse’s relationship to individual identity can be rescripted by examining its representation in formative cultural texts like the works of William Shakespeare. Through an integration of historical, literary and biomedical engineering perspectives on the pulse, this paper expands interpretations of pulselessness and advocates for the importance of cultural—as well as biomedical—knowledge to support patients with LVADs and those around them. In reconsidering figurative and literal representations of the heartbeat in the context of technology which removes the need for a pulse, this essay argues that narrative and metaphor can be used to reconceptualise the relationship between the heartbeat and identity.

Heart surgery and transplantation: innovations impacting on concepts of life and death

The development of heart surgery is briefly reviewed, and the impact it has made on our concepts of life and death are considered. For centuries, death was defined by the cessation of heart beat. In the early days of heart surgery in the 1940s and 1950s, the heart sometimes temporarily stopped beating, but could be resuscitated, and some concluded that the patient had been ‘dead’ for a period of time. Subsequently, when the patient’s brain and other vital organs were protected either by the induction of a state of total body hypothermia or by the support of a heart-lung machine, the heart was purposely stopped from beating for periods of a few minutes to even several hours, but the patient remained alive. When heart transplantation was introduced in 1967, for a period of time the patient not only had no heartbeat, but had no heart, yet was not dead. When total artificial hearts were introduced, the patient permanently had no heart, but remained alive. In the near future, it is likely that the native heart will be permanently replaced by a genetically-engineered pig heart. Organ transplantation, particularly of the heart, contributed further to our changing concepts of life and death. In 1963, surgeons began to remove organs from donors whose brain had been irreversibly damaged, and had been diagnosed as being ‘brain-dead’, but in whom the heart was still beating. By 1968, the beating heart was routinely removed from brain-dead donors and transplanted into recipients, but this was no longer considered to be illegal as brain death had become the definitive definition of death, not lack of a heart beat or even lack of a heart.

Animal, Mechanical, and Me

Organ donation and transplantation is a largely successful treatment used to replace failing organs. However, donation rates have never met the demand for transplantable organs. Biomedical researchers are exploring alternative sources from nonhuman animal donors such as pigs; improved biotechnological solutions such as total artificial hearts; and 3D printed organs developed from the recipient’s own cells. These solutions are in various stages of development, and they may or may not prove viable in terms of cost, functionality, and/or compatibility with the recipient’s body. In this chapter, I ask not about the viability of these proposed solutions, but rather, about the acceptability of the various technologies to potential recipients. Simply put: were these organ transplant alternatives to become available, would patients agree to them? Analyzing answers from focus group interviews and surveys, I use the responses to show that individuals imagine these various technologies as familiar or foreign, self or other, clean or dirty, and so on. People envisage that using different materials will certainly affect their bodies but also their subjectivities. New biotechnologies are raising questions about altering subjectivity through body modification, and the answers to these questions demonstrate ambiguity.