Abstract
Patients with chronic heart failure who are not eligible for heart transplant and whose life expectancy depends mainly on the heart disease may benefit from mechanical circulatory support. Mechanical circulatory support restores adequate cardiac output and organ perfusion and eventually improves patients' clinical condition, quality of life and life expectancy. This treatment is called destination therapy (DT) and we estimate that in Switzerland more than 120 patients per year could benefit from it. In the last 10 years, design of the devices, implantation techniques and prognoses have changed dramatically. The key to successful therapy with a left ventricular assist device is appropriate patient selection, although we are still working on the definition of reliable inclusion and exclusion criteria and optimal timing for surgical implantation. Devices providing best long-term results are continuous flow, rotary or axial blood pumps implanted using minimally invasive techniques on a beating heart. These new devices (Thoratec HeartMate II and HeartWare HVAD) have only a single moving part, and have improved durability with virtually 10 years freedom from mechanical failure. In selected patients, the overall actuarial survival of DT patients is 75% at 1 year and 62% at 2 years, with a clear improvement in quality of life compared with medical management only. Complications include bleeding and infections; their overall incidence is significantly lower than with previous devices and their management is well defined. DT is evolving into an effective and reasonably cost-effective treatment option for a growing population of patients not eligible for heart transplant, showing encouraging survival rates at 2 years and providing clear improvement in quality of life. The future is bright for people suffering from chronic heart failure.
Highlights
Up to 30% of stable patients listed for HTx deteriorate far enough to require high-urgency HTx or emergency left ventricular assist devices (LVADs) and we propose earlier implantation, before right-ventricular and multiorgan failure
As suggested by Miller et al [37], we should abandon the approach based on preimplant determination of whether a ventricular assist device for a given patient is a bridge to transplant or recovery or destination therapy
We will establish that a patient is in need of mechanical circulatory support, based on the presence of indications and absence of contraindications, and leave the question of duration of the support open depending on clinical evolution and organ availability
Summary
Patients with chronic heart failure who are not eligible for heart transplant and whose life expectancy depends mainly on the heart disease may benefit from mechanical circulatory support. Mechanical circulatory support restores adequate cardiac output and organ perfusion and eventually improves patients’ clinical condition, quality of life and life expectancy This treatment is called destination therapy (DT) and we estimate that in Switzerland more than 120 patients per year could benefit from it. When even the most advanced pharmacological therapy fails to achieve adequate organ perfusion in patients with chronic heart failure (CHF) with reduced ejection fraction, the only effective solution is mechanical circulatory support (MCS) [1]. In our country, DT will probably be generally accepted as one of the treatment options only if a national cost-effective analysis related to the Swiss healthcare system were to clearly prove its benefit
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