New role of ventricular assist devices as bridge to transplantation

Abstract

Purpose of reviewProgress of ventricular assist devices (VAD) technology led to improved survival and apparently low morbidity. However, from the European perspective, updated analysis of EUROMACS reveals a somewhat less impressive picture with respect to mortality and morbidity.Recent findingsWe describe the great demand of cardiac allografts versus the lack of donors, which is larger in Europe than in the United States. Technical progress of VADs made it possible to work out a modern algorithm of bridge-to-transplant, which is tailored to the need of the particular patient. We analyze the burden of patients undergoing bridge-to-transplant therapy. They are condemned to an intermediate step, coupled with additional major surgery and potential adverse events during heart transplantation.SummaryBased on current registry data, we do have to question the increasingly popular opinion, that the concept of heart transplantation is futureless, which seems to be for someone who treats and compares both patients (VAD and heart transplantation) in daily practice, questionable. Up to now, left ventricular assist device therapy remains a bridge to a better future, which means a bridge to technical innovations or to overcome the dramatic lack of donors in Europe.

Complications of left ventricular assist devices causing high urgency status on waiting list: impact on outcome after heart transplantation

“…This most probably relates to the previously discussed relatively long LVAD support times of HTx candidates in the Eurotransplant region, the distinct regional allocation policies, and ultimately, to the dramatically low organ donation rates within the distinct Eurotransplant region. [2][3][4]7,8,13 Compared with our previously published single-centre data on the impact of LVAD therapy on the outcome after HTx, we found similar results for the LVAD patients in this two-centre approach. 9 As a consequence, outcome after HTx in LVAD patients may not be affected by the occurrence of device-related complications but is endangered simply due to the prior implantation of a durable MCS device.…”

“…Compared with global registry data, survival after HTx was herein clearly inferior in all groups. This most probably relates to the previously discussed relatively long LVAD support times of HTx candidates in the Eurotransplant region, the distinct regional allocation policies, and ultimately, to the dramatically low organ donation rates within the distinct Eurotransplant region 2–4,7,8,13 . Compared with our previously published single‐centre data on the impact of LVAD therapy on the outcome after HTx, we found similar results for the LVAD patients in this two‐centre approach 9 .…”

“…Most likely, the dramatic donor organ shortage in Germany is the reason for both the prolonged LVAD support durations and, thereby, the cumulative increase in LVAD complication incidence in transplanted LVAD patients. Based on the different prioritization of LVAD patients on the waiting list for HTx in Europe and the USA and the small likelihood of a prompt HTx, Reineke and Mohacsi 13 even postulate that, in Germany, the decision to implant an LVAD nearly equals the concept of destination therapy. In fact, the latest consensus statement of the European Association for Cardio‐Thoracic Surgery suggests no longer differentiating between a BTT or destination therapy indication for durable mechanical circulatory support (MCS) implantation 14–20 .…”

Surgery for heart failure: Treatment options and implications

“…The main use of them is in bridge to transplant schemes (BTT). This is when a patient has met the requirements for a heart transplant and is awaiting a donor but would suffer serious physical consequences without continuous ventricular circulation 31 . A ventricular assist device would then maintain continuous circulatory flow until a donor is available for a heart transplant, improving symptoms and quality of life.…”

Outcome of patients on heart transplant list treated with a continuous-flow left ventricular assist device: Insights from the TRans-Atlantic registry on VAd and TrAnsplant (TRAViATA)

“…The United States (US) and Europe (EU) differ in a variety of factors related to CF-LVAD-strategy and HTx indications [6]. Relevant factors that may affect outcomes are numerous, the most obvious being the older age of transplant recipients in the US and older age of transplant donor hearts in the EU.…”