MEDICINE

REVIEW ARTICLE

The Current Status of Heart Transplantation

and the Development of "Artificial Heart
Systems"
Martin Strber, Anna L. Meyer, Doris Malehsa, Christiane Kugler, Andre R. Simon, Axel Haverich

SUMMARY
Background: In view of the major technical advances in
ventricular assist devices (VAD) in recent years, the authors
discuss the question whether these "artificial hearts" are
still no more than a temporary measure for patients awaiting
heart transplantation (HTx), or whether they can already be
used as an independent form of long-term treatment.
Methods: Statistics from Eurotransplant regarding heart
transplantations and transplant waiting lists in Germany
are presented. Technical developments in cardiac support
systems, the variation in results depending on the indication,
and the findings with respect to quality of life are all
discussed on the basis of a selective review of the literature
and the authors' own clinical experience.
Results: The waiting list for heart transplantation in
Germany has grown to a record size of nearly 800 patients,
while fewer than 400 hearts are transplanted each year.
Technical advances have improved outcomes in VAD therapy,
but the outcome depends on the patient's preoperative
condition. The physical performance of patients who have
received VAD is comparable to that of HTx patients;
nonetheless, HTx patients have a better quality of life.
Conclusions: Chronic VAD therapy has become a clinical
reality. Because of the greater number of patients awaiting
HTx, many will not receive their transplants in time. When
the decision to treat with VAD is made early, it can be used
as an alternative form of treatment with a comparable
one-year survival (>75%).
Dtsch Arztebl Int 2009; 106(2829): 4717
DOI: 10.3238/arztebl.2009.0471
Key words: heart transplantation, artificial heart,
heart failure, transplantation statistics, quality of life

Klinik fr Herz-, Thorax-, Transplantations- und Gefchirurgie, Medizinische

Hochschule Hannover: Prof. Dr. med. Strber, Dr. med. Meyer, Dr. med. Malehsa, Dr. rer. biol. hum. Kugler, PD Dr. med. Simon, Prof. Dr. med. Haverich

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DeuDeutsches rzteblatt International

he number of patients on the waiting list for a heart

transplant in Germany declined each year from
1998 to 2001, but the trend then reversed direction, with
a steady increase ever since. At the same time, the number
of heart transplantations performed per year has gone
down.
The causes of this development are multiple. One
explanation may be that the introduction of better conservative treatments for end-stage heart failure, such as
beta-blockers and biventricular pacemakers, at first led
to a temporary decline in the demand for heart transplants, but that transplantation again became a desirable
option later on in the course of the disease, once these
treatments had been exhausted.
Another explanation can be found in the general
demographic trend toward an increasing incidence of
end-stage heart failure. Thus, it could be stated with certainty in 2001 that a patient on the heart transplantation
waiting list would be able to undergo transplantation
within one year. In 2008, in contrast, there were 873 patients on the waiting list, while only 382 transplantations
were performed. As a consequence, many patients die
while waiting for a transplant (Figure 1).
As early as the year 2000, a new allocation strategy
was adopted to address this problem: priority in the
allotment of transplants has been given since then to patients who need them urgently. Eight years ago, 30%
(8 of 26) of the patients receiving heart transplants in
Hannover were rated as "high urgency" (HU) candidates;
the corresponding figure today is nearly 90% (28 of 32).
In September 2005, the HU criteria were made yet more
stringent (1), and, even still, there are continually about
40 patients nationwide who are on this highest level of
urgency. Patients with common blood groups and of
normal body size have hardly any chance any more of
receiving a heart transplant unless they are rated as HU.
Some transplantation centers now only register patients
for transplantation when they are in the HU category;
generally, this means that the patient requires intensive
care and is catecholamine-dependent.
If a patient in the HU category is in danger of dying
while waiting for a transplant, ventricular assist devices
(VAD) can be used as a temporizing measure until a
transplantable organ becomes available. Although this
strategy can be very successful in individual cases, it

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assist device), "LVAD" (left ventricular assist device),

and "rotary blood pumps" for the period 19702008
we will discuss the developments in LVAD technology
that now enable patients to survive for several years with
permanent circulatory support, and also the available
ways of lessening the risks and invasiveness of interventions of this type.

FIGURE 1

The development of artificial heart technology

The length of the waiting list and the number of heart transplantations performed each year in
Germany, 19982008 (data from Eurotransplant, www.eurotransplant.nl)

also worsens the imbalance between the number of

potential organ recipients and the number of transplantable organs.
Data from Europe show that, among all patients
receiving a VAD as a temporary treatment, only 25% go
on to receive a transplant within one year (2). This
necessarily creates a state of chronic circulatory support
with a left ventricular assist device (LVAD) for patients
who are cared for on an ambulatory basis and who must
live with such a device for an indefinite period of time.
In this articlebased on a literature search on the key
words "total artificial heart," "BVAD" (biventricular

Figure 2: Systems for use in patients with biventricular heart failure

a) A Total Artificial Heart (SynCardia) that is implanted orthotopically and powered by
a pneumatic console (photograph reproduced with the kind permission of SynCardia
Systems, Inc. [www.syncardia.com])
b) An extracorporeal artificial ventricle (the Thoratec Paracorporeal Ventricular Assist Device
[PVAD]), which can be used to assist the function of either the right or the left ventricle of
the heart and is powered similarly to the Total Artificial Heart (photograph reproduced with
the kind permission of the Thoratec Corporation)

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40 years ago, the functional replacement of the human

heart was already a topic of intense public interest, not
just because the first heart transplantation had been performed in December, 1967, but also because the development and clinical application of artificial hearts was
already underway even then. A pneumatically driven,
two-chambered apparatus was then being developed for
total heart replacement (3). Unlike heart transplantation,
however, the artificial heart failed to become established
in clinical practice in that early period (4), and the type
of artificial heart that was then under devlopment is in
clinical use today in only a few special situations. The
original type of artificial heart had major technical flaws,
and the need to power it with a very large, extracorporeal
console made it utterly impractical for permanent therapy
as we know it today (5).
In order to address these technical problems, the artificial ventricles were moved outside the body (Figure
2). This step meant that what had originally been intended
as an artificial heart was transformed into a ventricular
assist device (6). This technology was successfully
applied and is still in use today. Experience has shown
that the functional replacement of both cardiac ventricles is not necessary in every case; rather, left ventricular assistance alone usually suffices (7).
In the 1990s, implantable, electrically powered left
ventricular assist devices came onto the market. These
large, heavy displacement pumps were implanted in a
pocket below the diaphragm (8) and connected to the
apex of the left ventricle and to the ascending aorta.
They were connected to an external electric power supply
through a percutaneous cable: this was the origin of the
configuration that is still the most common one today
(9), i.e., an implanted pump with a transcutaneous
connection to a power supply (Figure 3). The unsatisfactory aspects of this solution were the size of the
apparatus, the noise it made, the risk of infection, and
limited mechanical durability. Using such a device as
the sole method of treatment (destination therapy) was
found to give patients a significantly higher chance of
survival at one year than conservative treatment did (the
REMATCH trial, [10]), yet the limited mechanical durability of the apparatus became a critical issue at two
years, at which time the survival advantage was no more
than marginal.
The second generation of left ventricular assistance
devices (LVADs) consisted of axial pumps. The new
technology opened up new possibilities: these LVADs
provide continuous blood flow without valves, are relatively small and light, and remain mechanically stable
for years. When they were first used, there were major
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Figure 3: Left ventricular assistance system

a) Schematic representation of the current method of left ventricular assistance with an implanted axial pump (Thoratec HeartMate II) and
extracorporeal components (controller, batteries) (reproduced with the kind permission of the Thoratec Corporation)
b) Chest x-ray

problems relating to coagulation (11), but technical

modifications and improved anticoagulation schemes
have largely circumvented these difficulties. The incidence of infections and neurological complications is
also much lower than before: first-generation LVADs
were found, in the REMATCH trial (10), to be associated
with 0.39 severe neurological disturbances per patientyear, while the comparable figure in a study of axial
pumps (second-generation LVADs) was only 0.18 strokes
per patient-year (12). The latter results were equaled by

an incidence of 0.18 strokes per patient-year in a trial of

a third-generation device (Ventracor) (13).
Moreover, it has become clear that continuous blood
flow, with loss of the pulse, is physiologically (14) entirely unproblematic (15). The neurocognitive disturbances
associated with severe heart failure can be improved
with pulseless LVADs, just as they can with pulsatile
devices (16). The patient also remains able to compensate
for the increasing physical stress of exercise after the native heart has been relieved of its functional burden (17).

TABLE
Advantages and disadvantages of heart transplantation versus cardiac assistance systems

Heart transplantation

Cardiac assistance systems

Advantages

> Definitive treatment

> Normal physical activity possible
> Good long-term prognosis

> Immediately available

> Planned intervention
> Good level of physical activity achievable
> Recovery of native heart possible (ca. 8%)

Disadvantages

> Lack of donor organs

> Disease can arise in the donor organ
> Risk of transplant vasculopathy
> Immune suppression:
renal failure
neoplasia
susceptibility to infection
diabetes mellitus
hypertension

> Dependency on device

> Device must be continually supplied with power
> Cardiac arrhythmia
> Anticoagulation (hemorrhage, stroke)
> Risk of infection (Driveline*)

* percutaneous cable connection

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personnel who are called to see such patients and then

find them pulseless, but alert and talking!

FIGURE 4

Indications and results

Risk scores regarding the preoperative condition and course of patients receiving ventricular
assist devices (VAD) (19). These observations were made in 222 patients who had received
VAD as permanent treatment. Note that older, first-generation VAD were used here for reasons
related to device approval. (From: Lietz K, Long JW, Kfoury AG et al.: Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: Implications
for patient selection. Circulation 2007; 116: 497505. Reproduced with the kind permission
of Lippincott William & Wilkins, Baltimore.)

Because of potential problems in the non-invasive measurement of blood pressure, as well as the inability to
record a capillary pulse, the usual treatment modalities
need to be altered for patients bearing pulseless LVADs.
In particular, when medical or surgical treatments are
needed independently of the cardiac situation, consultation with an implanting center is recommended. These
patients also have an elevated tendency to bleed, e.g.,
during dental or surgical procedures, partly because of
the necessary anticoagulation, partly because of acquired
platelet dysfunction, and perhaps also because of an
acquired von Willebrand syndrome (18). It follows that
such procedures should only be performed in specialized
centers. These patients often do not lose consciousness even when they go into atrial fibrillation. One can
well imagine the consternation of emergency medical

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In the past, artificial cardiac support systems were only

implanted in patients who would otherwise have had no
chance of survival. Accordingly, the high perioperative
morbidity and mortality were not solely due to the dangers
of the device itself and its implantation, but also in large
measure to the preexisting cardiac shock and the consequent multiple organ failure. Unlike heart transplantation,
which, at present, can no longer be ethically or legally
offered to patients with a very poor prognosis in view of
the lack of transplantable organs, ventricular assist devices
are, in principle, available for use in all patients at all
times (Table). It follows that the extreme reluctance to
use VADs prevailing in Europe today can only be understood as a product of the historical setting.
Risk assessment has been attempted in order to determine how the patient's preoperative condition affects
the postoperative outcome of VAD implantation.
In this connection, the finding reported by Lietz et al.
(19) in 2007 needs to be emphasized: even a moderate
degree of two-organ or multiple organ failure massively
affects the outcome after an assist device has been implanted (Figure 4). Patients with a risk score below 17
achieve greater than 70% survival at one year, while
those with a risk score of 17 or higher have a one-year
survival rate no higher than 30%. Thus, a patient with a
platelet count below 148 000 per microliter and a plasma
albumin concentration below 3.3 g/dL, under afterloadreducing treatment and with a moderately elevated
blood urea nitrogen concentration, is already in a highrisk category even if no intravenous inotropic agents are
being administered. The decision to use a ventricular
assist device must be made in timely fashion, before
multiple organ failure sets in, if a successful outcome is
to be achieved (20).
The hypothesis guiding this article is that the lower
invasiveness of the implantation of modern support
systems and the possibility of permanent therapy with
them can lead to more timely decisions to treat, and thus
to better outcomes. The risk to the patient is greatest in
the perioperative phase, it is largely a function of the
patient's preoperative condition (Figure 5). Device failuresuch as is still encountered with pulsatile LVADs
(10)has little influence on outcomes later on in the
course of treatment (2).
At the Hannover Medical School, the decision to treat
early has already reduced the perioperative mortality
from 25% (18 of 70 patients) in 20042006 to 12% in
2007 and 10% (2 of 22 patients) in the first half of 2008
(p < 0.05). As described by Lietz et al. (19), it is important that the decision to treat should be mainly based, not
on hemodynamic parameters, but rather on indicators of
incipient organ dysfunction (the international normalized
ratio [INR]), the serum albumin concentration, renal
function parameters, and the platelet count (Figure 4).
Moreover, the markedly improved outcomes that are
currently seen have come about through the establishment
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of interdisciplinary teams and integrated patient care at

clinical institutions with active cardiac support programs. The improved outcomes also clearly indicate
that this type of treatment is becoming established as
permanent therapy (21).
Although the one-year survival after heart transplantation around the world has remained well over 80% for
several years now (as documented by the International
Society for Heart and Lung Transplantation, with data
from 76 538 transplantations performed up to 2006), the
corresponding figure for Germany in 2007 was only
73% among 252 heart transplantations (data from the
German Federal Quality Assurance Office, Bundesgeschftsstelle Qualittssicherung [BQS]). A major factor
leading to this relatively low figure is in-hospital lethality, which has risen over the last three years to the latest
figure of 22.2%. Potential causes of this development
include the lack of transplantable organs in Germany
and the allocation of transplants to recipients in intensive
care units who are already suffering from multiple organ
failure.
A number of studies have already shown better oneyear survival figures after LVAD implantation than after
heart transplantation in Germany (13), yet the comparability of the patient groups is highly questionable. The
most pertinent figures for survival after LVAD implantation are those of a retrospective European study (2):
the one-year survival in this study, just over 70%, was
on the same order of magnitude as that of heart transplantation in Germany.
The treatment algorithm for end-stage heart failure
should take risk scores into account, both for transplantation and for LVAD implantation. This carries the
potential of considerably improving the overall outcome
for these high-risk patients, whichever of the two treatments they receive.

Health-related quality of life

There are major differences between heart transplant
recipients on the one hand and artificial heart recipients
on the other. Heart transplantation carries with it a
lifelong need for immunosuppressive treatment, with
the attendant major side effects. Permanent treatment
with an LVAD necessitates both anticoagulation and the
continuous provision of electric current to the device.
The patient's perception of these restrictions on his or
her quality of life depends not only on the course of
disease before and after surgical treatment, but also on
personal coping ability.
A current study from the Netherlands shows that even
patients with first-generation support devices experience
a marked improvement of physical performance, with
little or no restriction of their aerobic capacity. Patients
who had received heart transplants did even better (22).
Some of the devices used in this study, however, must be
regarded as out of date.
To address the question of physical performance and
quality of life in patients with modern cardiac support
systems, the authors used spiroergometry to monitor the
physical functioning of the heart transplant patients

FIGURE 5

Results of the first 100 implantations of an axial pump (HeartMate II)

in Europe (2). The individual curves represent survival, transplantations, deaths, and explantations of the VAD (ventricular assist device)
after recovery of left ventricular function. These data were acquired
retrospectively rather than in a prospective clinical study. (From:
Strber M, Sander K, Lahpor J et al.: HeartMate II left ventricular
assist device; early European experience. Eur J Cardiothoracic Surg
2008; 34: 28994. Reprinted with the kind permission of Elsevier,
Oxford, U.K.)

whom they cared for as outpatients, as well as that of

their patients with artificial heart systems as permanent
treatment, and also monitored their psychosocial competence (health-related quality of life, HRQoL) using
the Medical Outcomes Study Short-Form General
Health Survey (SF-36). Furthermore, in an as yet unpublished study of the Department of Cardiothoracic,
Transplant, and Vascular Surgery at the Hannover
Medical School, 53 heart-transplant patients and 21
LVAD patients were examined six to nine months after
the surgical procedure.
Both groups were composed exclusively of men,
most of whom suffered from dilated cardiomyopathy.
The mean age was 52 12 years in the heart transplantation (HTx) group and 47 13 years in the LVAD group
(p = 0.07). With regard to cardiopulmonary performance,
the maximal performance capacity in the HTx group
was found to be 84 27 W (watts), as compared to 105
16 W in the LVAD group (p < 0.026). In both groups,
these figures corresponded to 52% of the age-adjusted
norm. The maximal oxygen consumption (VO2 max in
mL/min/kg) was 17.4 3.5 in the HTx group and 20.5
4.6 in the LVAD group (p<0.04).
We interpret these data as showing that both forms of
treatment can lead to an acceptable outcome in terms of
cardiopulmonary performance, with slightly better results for LVAD. The latter are possibly accounted for by
the somewhat younger age of the LVAD patients and by
their markedly shorter disease course before treatment,
in consequence of which they have not yet undergone
severe muscular deconditioning during their period of

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Figure 6: The development of left-ventricular assist technology (illustrative examples).

From left to right:
1st generation: a pulsatile, electrically powered ventricular assist device (VAD) (Thoratec HeartMate I)
2nd generation: a non-pulsatile axial pump (the Thoratec HeartMate II)
3rd generation: a non-pulsatile centrifugal pump (the HeartWare HVAD)
4th generation: a miniature left-ventricular assist device (LVAD) for partial circulatory support (CircuLite Synergy)
(Photographs reproduced with the kind permission of the Thoratec Corporation, HeartWare International, and CircuLite, Inc.)

their heart failure. With regard to physical performance

ability after heart transplantation, it is known from earlier
studies that muscular deconditioning (23) is difficult to
reverse after transplantation, and that improvement is
only possible through a continuous program of muscle
training. The inhibitory effect of immune suppression
on the skeletal musculature may also contribute to
deconditioning (24).
With regard to the quality of life, as assessed on a scale
from 0 to 100, no differences were found in the two
groups' overall self-ratings: 50 30 in the HTx group
and 49 27 in the LVAD group. The heart transplant
patients, however, gave themselves higher ratings than
the LVAD patients in the SF-36 subanalyses concerning
"physical functioning" (p<0.04), "vitality" (p<0.03),
and "mental health" (p<0.01).

Perspectives
In view of the demographic trend toward an aging population, waiting lists for heart transplantation can be
expected to grow longer. It would be desirable for this
development to be met by a correspondingly greater
willingness on the part of the public to donate organs.
The technology of permanent mechanical circulatory
support has now developed onward into the third generation of assist devices (centrifugal pumps) (Figure 6).
These new LVADs are smaller and more efficient than
those previously in use: they weigh only 140 g and can
completely assume the tasks of the left ventricle of the

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heart with an energy consumption of less than 5 W.

Systems are also now available for partial circulatory
support with flow rates from 1.5 to 2 liters/minute. These
systems are attractive because they can be implanted in
relatively non-invasive fashion and because they consume
very little energy.
The quality of the external components, such as batteries and cable connections, could still use marked
improvement. We cannot yet expect completely implantable LVADs (25) to become available any time
soon, in view of the complexity and lack of durability of
these devices. Rather, the next avenue of investigation at
present is the transcutaneous generation of current by
induction, which will permit the elimination of the cable
that now connects the external and internal components
of the device. This should improve the patients' quality
of life and reduce the incidence of life-threatening complications.
Conflict of interest statement
Professor Strber is a member of the European Advisory Board of the Thoratec
Corporation as well as a physician evaluator of the HeartWare LVAD system
(pilot study) of HeartWare International, Inc.
Dr. Malehsa has received reimbursement of travel expenses from the Thoratec
Corporation. Dr. Meyer, Dr. Kugler, Dr. Simon, and Prof. Haverich declare that
they have no conflict of interest as defined by the guidelines of the International
Committee of Medical Journal Editors.
Manuscript received on 9 September 2008; revised version accepted on
2 January 2009.
Translated from the original German by Ethan Taub, M.D.

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REFERENCES
1. Komoda T, Hetzer R, Lehmkuhl HB: Destiny of candidates for heart
transplantation in the Eurotransplant heart allocation system. Eur J
Cardiothor Surg 2008; 34: 3016.
2. Strber M, Sander K, Lahpor J et al.: HeartMate II left ventricular
assist device; early European experience. Eur J Cardiothoracic Surg
2008; 34: 28994.
3. Cooley DA: The total artificial heart. Nature Medicine 2003; 9:
10811.
4. Bcherl ES, Henning E, Baer P, Frank J, Lamm W, Zartnack F: Status
of the Artificial Heart Program in Berlin. World J Surg 1985; 9:
10315.
5. Cooley DA, Liotta D, Hallman GL, Bloodwell RD, Leachman RD,
Milam JD: Orthotopic Cardiac Prosthesis for Two-Staged Cardiac
Replacement. A J Cardiologie 1969; 24: 72330.
6. Pennington DG, Kanter KR, McBride LR et al.: Seven years experience with the Pierce-Donachy ventricular assist device. J Thorac
Cardiovasc Surg 1988; 96: 90141.
7. Pennington DG, Reedy JE, Swartz MT et al.: Univentricular versus
biventricular assist device support. J Heart Lung Transplant 1991;
10: 25863.
8. Frazier OH: First use of an untethered, vented electric left ventricular
assist device for long term support. Circulation 1994; 89: 290814.
9. Vetter HO, Kaulbach HG, Schmitz C et al.: Experience with the Novacor left ventricular assist System as a bridge to cardiac transplantation, including a new wearable system. J Thorac Cardiovasc Surg
1995; 109: 7480.
10. Rose EA, Moskowitz AJ, Heitjan DF et al.: Long term mechanical left
ventricular assistance for end stage heart failure. N Engl J Med
2001; 345: 143443.
11. Rothenburger M, Wilhelm MJ, Hammel D et al.: Treatment of thrombus formation associated with the MicroMed DeBakey VAD using recombinant tissue plasminogen activator. Circulation 2002; 106:
I18992.
12. Miller LW, Pagani FD, Russell SD et al.: Use of continuous-flow
device in patients awaiting heart transplantation. N Engl J Med 2007;
357: 88596.
13. Esmore D, Spratt P, Larbalestier R et al.: VentrAssist left ventricular
assist device: clinical trial results and Clinical Development Plan
update. Eur J Cardiothorac Surg 2007; 32: 73544.
14. Wieselthaler GM, Riedl M, Schima H et al.: Endocrine function is not
impaired in patients with a continuous MircoMed-DeBakey axial flow
pump. J Thorac Cardiovasc Surg 2007; 133: 26.

15. Radovancevic B, Vrtovec B, de Kort E, Radovancevic R, Gregoric ID,

Frazier OH: End-organ function in patients on long term circulatory
support with continuousor pulsatileflow assist devices. J Heart
Lung Transplant 2007; 26: 8158.
16. Zimpfer D, Wieselthaler G, Czerny M et al.: Neurocognitive function
in patients with ventricular assist devices: a comparison of pulsatile
and continuous blood flow devices. Asaio J 2006; 52: 247.
17. Akimoto T, Yamazaki K, Litwak P et al.: Rotary blood pump flow
spontaneously increases during exercise under constant pump
speed: results of a chronic study. Artif Organs 1999; 23: 797801.
18. Geisen U, Heilmann C, Beyersdorf F et al.: Non-surgical bleeding
in patients with ventricular assist devices could be explained by
acquired von Willebrand disease. Eur J Cardiothorac Surg 2008; 33:
67984.
19. Lietz K, Long JW, Kfoury AG et al.: Outcomes of left ventricular assist
device implantation as destination therapy in the post-REMATCH
era: Implications for patient selection. Circulation 2007; 116:
497505.
20. Potapov EV, Loforte A, Weng Y et al.: Experience with over 1000 implanted ventricular assist devices. J Card Surg 2008; 23: 18594.
21. Osaki S, Edwards NM, Velez M et al.: Improved survival in patients
with ventricular assist device therapy: the University of Wisconsin
experience. Eur J Cardiothor Surg 2008; 35: 2818.
22. Pruijsten RV, Jonge N de, Kirkels JH et al.: Left ventricular assist
device: a functional comparison with heart transplantation. Neth Heart
J 2008; 16: 416.
23. Tegtbur U, Busse MW, Jung K, Pethig K, Haverich A: Time course of
physical reconditioning during exercise rehabilitation late after heart
transplantation. J Heart Lung Transplant 2005; 24: 2704.
24. Mercier JG, Hokanson JF, Brooks GA: Effects of cyclosporine A on
skeletal muscle mitochondrial respiration and endurance time in
rats. Am J Respir Crit Care Med 1995; 151: 15326.
25. Pae WE, Connell JM, Adelowo A et al.: Does total implantability
reduce infection with the use of a left ventricular assist device? The
LionHeart experience in Europe. J Heart Lung Transplant 2007; 26:
21929.
Corresponding author
Prof. Dr. med. Martin Strber
Klinik fr Herz-, Thorax-, Transplantations- und Gefchirurgie
Medizinische Hochschule Hannover
Carl-Neuberg-Str. 1
30625 Hannover, Germany
strueber.martin@mh-hannover.de

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