Left Ventricular Assist Devices vs. Transplant | Ten Points to Remember

Mancini D, Colombo PC.
Left Ventricular Assist Devices: A Rapidly Evolving Alternative to Transplant. J Am Coll Cardiol 2015;65:2542-2555.

The following are 10 points to remember about left ventricular assist devices (LVADs) as a rapidly evolving alternative to transplant:

  1. With a persistent donor shortage and an increasing number of patients with Stage D heart failure, LVADs have been used as bridge to heart transplant for those who qualify for transplant (bridge to transplant) or as a substitute in those who do not (destination therapy).
  2. Despite ongoing measures to increase access to donor organs, organ availability remains a major limitation to heart transplant.
  3. The current strategy for the management of refractory Stage D heart failure with reduced ejection fraction (HFrEF) patients is to initially screen for heart transplant, with destination therapy VADs considered as secondary treatment for those who do not qualify.
  4. The current algorithm for screening patients for advanced HF therapies may need to be revisited, with a shift to considering patients initially for destination VAD and heart transplant reserved for selected patients or as bailout therapy.
  5. VAD support offers improved quality of life and survival compared to medical therapy, and in some cases, 2-year outcomes comparable to heart transplant. There are now more LVAD implants performed per year than heart transplants.
  6. LVAD complications persist and may have lessened enthusiasm for investigating LVAD therapy in less sick patients; however, technology continues to advance rapidly.
  7. Smaller devices, total implantability, pulsatility, and remote monitoring are being investigated and will broaden application of VAD technology.
  8. Clinical trials are needed to determine which patients benefit most from LVAD support versus heart transplantation.
  9. LVAD technology is evolving rapidly and its accessibility is increasing when compared to heart transplant.
  10. In the future, VADs may be considered initial therapy for Stage D HF, with heart transplant reserved for VAD failures and selected patients.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Statins, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support

Keywords: Algorithms, Antineoplastic Combined Chemotherapy Protocols, Dexamethasone, Doxorubicin, Heart Failure, Heart Transplantation, Heart-Assist Devices, Quality of Life, Survival, Vincristine

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