Terminal heart failure: who should be transplanted and who should have mechanical circulatory support?

PURPOSE OF REVIEW: Permanent long-term mechanical circulatory support (MCS) is currently reserved for patients who are transplant ineligible. In light of improved outcomes with current continuous flow devices, increased interest has focused on the potential extension of MCS therapy to ambulatory advanced heart failure patients and as an alternative to cardiac transplantation.

RECENT FINDINGS: Average 1-year and 2-year survival with heart transplantation is about 85 and 80%, and with MCS therapy, it is 85 and 70% (with censoring at transplant). Specific subsets of destination therapy patients enjoy survival out to 2 years, which is comparable with transplant survival. Risk factor analyses identify similar risk profiles for each therapy. Life satisfaction after each is highly dependent on the frequency and severity of adverse events, which are quite different for these interventions. Patients with long expected waiting times will likely be the initial group for triage off the transplant wait list to MCS therapy.

SUMMARY: MCS has progressively improved and may become a reasonable alternative to transplantation for highly selected patients with long expected waiting time. More routine extension of MCS therapy to the transplant population awaits further reduction of major adverse events, miniaturized devices, and less invasive implant techniques.