Device Therapy and Cardiac Transplantation for End-Stage Heart Failure

https://doi.org/10.1016/j.cpcardiol.2009.09.001Get rights and content

Abstract

The prevalence of heart failure is increasing, and the prognosis of end-stage heart failure remains dismal. The gold-standard therapy in end-stage heart failure remains cardiac transplantation at the present time, but there is a great excess of eligible candidates compared with the number of donor organs. Advances in mechanical support, the development of the left ventricular assist device (LVAD), and the total artificial heart has reduced mortality and morbidity in patients awaiting transplantation, and LVADs are now approved as an strategy for destination therapy. Miniaturization, increased device durability, and complete implantability may render LVADs an option in earlier stages of heart failure, as a bridge to myocardial recovery or even as a viable alternative to transplantation. Alternative strategies under investigation are cell therapy and xenotransplantation. In the present article, current and potential future therapeutic options in end-stage heart failure are reviewed.

Section snippets

Background

An estimated 5.7 million people carry a diagnosis of heart failure in the USA (2006 figures), and almost 300,000 people die of heart failure in the USA each year.1 The prevalence of heart failure is increasing and increases with age.1 In the Western world, most heart failure is related to coronary disease, and although the survival of patients post acute myocardial infarction has improved, this has resulted in an increase in the numbers of patients ultimately developing heart failure.2 In fact,

A Brief History of Mechanical Support in Cardiac Failure

The development of cardiopulmonary bypass technology in the 1950s was the landmark achievement that greatly assisted the development of more permanent means of mechanical cardiac support.9 The first known mechanical support device dates back to Russia in the 1940s with the work of Dr. Vladimir Demikhov, who successfully implanted an artificial heart into a canine model, which supported the animal for over 5 hours.10 The first successful mechanical support device in humans was implanted by Dr.

Historical Perspective

Orthotopic cardiac transplantation as it exists today is a highly successful procedure for the treatment of end-stage heart disease and is the result of over 100 years of investigation and research.66 The concept of transplanting solid organs dates back to the 19th century, but the necessary surgical techniques were not developed until the 1890s, with the work of Alexis Carrel, who perfected a vascular anastomosis technique that allowed heterotopic transplantation of kidneys into the necks of

Conclusions

Cardiac replacement therapy in end-stage heart failure is at a crossroads. The art and science of cardiac transplant medicine has been perfected since the first transplant in 1967 and outcomes continue to improve. However, the number of transplants being performed worldwide is far outnumbered by the number of potential candidates, as donor hearts are a very limited resource. Advances in destination device therapy may provide a viable long-term solution for many patients, with either support of

Acknowledgments

The authors extend their thanks to the staff of the William J. Von Liebig Transplant Center and especially to Dr. Dylan V. Miller and Dr. Henry D. Tazelaar from the Department of Pathology for assistance with figures. The generous permission for use of figures and tables by the International Society for Heart and Lung Transplantation, and the incorporated companies of Thoratec, Jarvik Heart, Ventracor, Syncardia Systems, Abiomed, and Circulite, are gratefully appreciated. Last, the authors

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