Mechanical circulatory support for advanced heart failure: where does it stand in 2003?

Abstract

Today, the lifetime risk of developing heart failure is 1 in 5 for both men and women.1 This high risk underscores the need for effective therapies to treat terminal heart failure unresponsive to conventional treatment. Cardiac transplantation, when possible, offers not only significant palliation but also a real opportunity for meaningful long-term survival. However, posttransplantation mortality and morbidity have improved little over the past decade, and because of the shortage of suitable donor organs, this therapy will never have more than a minimal epidemiological impact on heart failure. The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. To expand the therapeutic options for treating end-stage heart failure, the National Institutes of Health initiated research in the mid-1970s designed to develop mechanical circulatory support (MCS) devices that could provide destination therapy for this condition. The devices developed from this program were first used clinically, however, as bridges to transplantation in the mid-1980s. These implantable MCS devices have now been employed as a bridge to transplantation in more than 4000 patients worldwide. In 2002, on the basis of the results of the Randomized Evaluation of Mechanical Assistance for the Treatment of Chronic Heart failure (REMATCH) trial,2 implantable MCS systems were approved for destination therapy in patients who were not acceptable candidates for cardiac transplantation. Despite these advances, numerous questions remain about the ultimate goals of MCS and the role of this technology in treating heart failure. Who are the best candidates for these devices, and what should be the therapeutic goals in each case? What adjuncts can be expected to maximize the benefits of MCS? How can future devices best be developed and studied? To illustrate where this technology stands in 2003 and how it can be expected to develop, …