Mechanical Ventricular Assistance as Destination Therapy for End-Stage Heart Failure: Has it Become a First Line Therapy?

Abstract

Patients with end-stage heart failure have poor quality of life and prognosis. Therapeutic options are scarce and are not available for all. Only few patients can be transplanted every year. Several medical and surgical strategies have shown limited ability to influence prognosis and quality of life. In the past years, technological progress has realized devices capable of providing appropriate hemodynamic stabilization and recovery of secondary organ failure. Recently, these devices have been assessed as definitive treatment for patients who do not qualify for transplantation or/and instead to transplantation (“destination therapy”). This indication is increasingly considered following the results of newest clinical study reporting long-term survival without device correlated adverse events using last generation devices, and acceptable quality of life. The current knowledge about destination therapy and some original data from the DAVID Study (an Italian multicenter prospective study designed to evaluate the patient’s survival rate and quality of life of patients implanted with these new devices as long-term support or destination therapy) are summarized herein.Key PointsEnd-stage heart failure (NYHA class IV or stage D) is a vastly growing problem, with a poor prognosis and limited therapeutic options.Heart Transplantation is nowadays the “gold standard” treatment albeit its inability to serve to the current demand let alone the future one.The REMATCH study has demonstrated that first generation implantable devices, even with their high number of complications (infectious and thromboembolic events), allowed an improvement of quality and duration of life compared to medical therapy. Further studies have shown that the evolution of VAD technology has reduced device-related complications and consequently improved survival and quality of life of patients with results, according to some authors, similar to cardiac transplantation at least at 2 years from the implantation.Biotechnology advancements have led to the creation of a new generation of implantable mechanical assist devices: the continuous-flow rotary pumps. Recently entered into clinical use, they seem to represent a promising solution to end -stageheart failure allowing long-term assistance and an adequate standard of living (Destination Therapy/Bridge to Life).The DAVID Study, an Italian multicenter prospective study, reports encouraging results in terms of late outcome and quality of life in patients implanted with newest continuous-flow devices as destination therapy. More and more numerous studies are needed to confirm our initial data and for laying the foundations for this new therapeutic frontier face to cardiac transplantation.

National Burden of Heart Failure Events in the United States, 2006 to 2014

“…3 Improved treatment modalities may also improve outcomes, and more patients are using LVAD as destination therapy rather than only as a bridge to transplant therapy. 45, 46 Another potential avenue for improvement of HF outcomes is use of cardiac rehabilitation. Cardiac rehabilitation has been found to reduce hospitalization, is recommended for stable outpatients with HF, and is covered as a Medicare fee for service benefit, yet only one tenth of eligible HF patients receive a referral.…”

Microfluidic Approaches for the Assessment of Blood Cell Trauma: A Focus on Thrombotic Risk in Mechanical Circulatory Support Devices

“…I) are miniaturized electrically powered pumps, wherein a rotating (axial or centrifugal) impeller delivers a steady propulsive energy driving a continuous blood flow from the left ventricular apex to the aorta (12). LVAD therapy has been shown to be effective to prolong recipient's survival rate (80% and 70% at one- and two-year post-implant, respectively) with respect to patients receiving medical therapy or pharmacologic management (50% at 1 year), with remarkable improvement of heart functionality and patients' quality of life (11–14). Implantation of TAH represents the surgical treatment option for full circulatory replacement in patients with irreversible biventricular failure.…”

“…recipient's survival rate (80% and 70% at one-and two-year post-implant, respectively) with respect to patients receiving medical therapy or pharmacologic management (50% at 1 year), with remarkable improvement of heart functionality and patients' quality of life (11)(12)(13)(14). Implantation of TAH represents the surgical treatment option for full circulatory replacement in patients with irreversible biventricular failure.…”

Synchronization of a Soft Robotic Ventricular Assist Device to the Native Cardiac Rhythm Using an Epicardial Electrogram

“…Clinicians and engineers have been working for decades to find a solution for patients with end-stage heart failure and various devices have been proposed [1]. Nowadays, ventricular assist devices (VADs) are used as a bridge to recovery, a destination therapy, or a bridge to transplantation [2]. The main disadvantage of the current VAD designs is that blood is continuously pumped through an artificial lumen of the device.…”