Mandeep R. Mehra

Should Left Ventricular Assist Device Be Standard of Care for Patients With Refractory Heart Failure Who Are Not Transplantation Candidates?Response to Jessup and Owens: Left Ventricular Assist Devices Should Not Be Standard of Care for Transplantation-Ineligible Patients

At 40 years of age, the lifetime risk of developing heart failure (HF) is 1 in 5 for men and women in the United States. Approximately half of patients who are ultimately diagnosed with HF will die within 5 years1; the associated morbidity, hospitalization rate, and loss of functional capacity are more difficult to calculate. Among the 5 million American patients currently living with HF, it is estimated that 200 000 patients have American College of Cardiology/American Heart Association stage D or refractory HF, resulting in markedly diminished functional status and survival.1,2 In 2012, 2 therapies are available to potentially prolong survival and to improve quality of life for end-stage HF patients: heart transplantation and long-term mechanical circulatory support in the form of a ventricular assist device (VAD). For permanent mechanical support, also referred to as destination therapy (DT), the Food and Drug Administration approved the use of the HeartMate II (Thoratec Corp, Pleasanton, CA) left ventricular assist device (LVAD) in January 2010. This device supports only the left ventricle; no biventricular device is approved for long-term therapy at this time.nnResponse by Mehra and Domanski on p 3094nnMany advanced HF patients are not appropriate candidates for transplantation or permanent LVAD because of comorbid conditions or age. After excluding these patients, clinicians must critically evaluate individual patient eligibility for transplantation or VAD. The indications for and complications expected after each procedure are increasingly recognized as distinct; the skills needed by clinicians who must care for these 2 types of patients are garnered in 2 complementary but separate experiential care settings. The therapies are neither equivalent in historical experience and outcomes nor interchangeable. Transplantation has been available for decades, with well-documented selection criteria, management protocols, and outcomes. As we begin to understand how to appropriately …At 40 years of age, the lifetime risk of developing heart failure (HF) is 1 in 5 for men and women in the United States. Approximately half of patients who are ultimately diagnosed with HF will die within 5 years1; the associated morbidity, hospitalization rate, and loss of functional capacity are more difficult to calculate. Among the 5 million American patients currently living with HF, it is estimated that 200 000 patients have American College of Cardiology/American Heart Association stage D or refractory HF, resulting in markedly diminished functional status and survival.1,2 In 2012, 2 therapies are available to potentially prolong survival and to improve quality of life for end-stage HF patients: heart transplantation and long-term mechanical circulatory support in the form of a ventricular assist device (VAD). For permanent mechanical support, also referred to as destination therapy (DT), the Food and Drug Administration approved the use of the HeartMate II (Thoratec Corp, Pleasanton, CA) left ventricular assist device (LVAD) in January 2010. This device supports only the left ventricle; no biventricular device is approved for long-term therapy at this time.nnResponse by Mehra and Domanski on p 3094nnMany advanced HF patients are not appropriate candidates for transplantation or permanent LVAD because of comorbid conditions or age. After excluding these patients, clinicians must critically evaluate individual patient eligibility for transplantation or VAD. The indications for and complications expected after each procedure are increasingly recognized as distinct; the skills needed by clinicians who must care for these 2 types of patients are garnered in 2 complementary but separate experiential care settings. The therapies are neither equivalent in historical experience and outcomes nor interchangeable. Transplantation has been available for decades, with well-documented selection criteria, management protocols, and outcomes. As we begin to understand how to appropriately …