Left ventricular assist devices (LVADs) have come a long way, but the next few
years may tell the real story as to where this fast-growing field is heading. A whirl
of activity, these high-tech devices are consistently advancing, with concomitant
improvements in implantation technique, patient selection, and patient management. However, complication rates remain high as do costs, but there is reason to
believe both will come down and, if all goes as planned, LVADs may become the
new heart transplants.
“T
here has been tremendous progress made
in mechanical circulatory support over the
past decade,” said G. William Dec, MD,
from Massachusetts General Hospital, Boston,
MA, “and I think that we are almost at the cusp
of when we are going to be offering our patients
an LVAD as opposed to a transplant as primary
therapy.”
And in a JACC State-of-the-Art review on
LVADs from June 2015,1 Donna Mancini, MD,
and Paolo C. Colombo, MD (both from Columbia University, New York, NY), noted that, while
the 2013 International Society of Heart Lung
Transplant (ISHLT) mechanical devices guidelines
recommend first asking whether the patient is a
candidate for a heart transplant, this may soon
change. They wrote, “With the rapid advances in
mechanical circulatory support, this algorithm
may be revised in the near future such that the
initial question is eligibility for destination therapy
(DT), followed by heart transplantation candidacy
and palliation.”
Where We’re Headed: Destination LVAD
Use of an LVAD for DT (i.e., the LVAD is the only
option, not a bridge to anywhere) currently is
indicated for patients with New York Heart Association (NYHA) class IV end-stage ventricular
heart failure (HF) who are not candidates for
heart transplant and, according to the Centers for
Medicare & Medicaid Services,2 meet all of the
following conditions:
• Have failed to respond to optimal medical management (including beta-blockers and angiotensin-converting enzyme inhibitors if tolerated)
for at least 45 of the last 60 days, or have been
balloon pump dependent for 7 days, or intravenous (IV) inotrope dependent for 14 days;
• Have an LV ejection fraction (LVEF) <25%; and
• Have demonstrated functional limitation with
a peak oxygen consumption of ≤14 ml/kg/min
unless balloon pump or inotrope dependent or
physically unable to perform the test.
ACC.org/CSWN
Mechanical circulatory support (MCS) as DT
constitutes a large and growing proportion of
overall implants. In the United States, the percentage of patients receiving a durable device as DT
has increased from 14.7% in 2006-2007 (n = 64)
to 19.6% in 2008-2010 (n = 666) to 41.6% in
2011-2013 (n = 2,781).3 Similarly, the proportion
of patients actually listed for cardiac transplant
at the time of implant has decreased from 42.4%
(2006-2007) t