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J Thorac Cardiovasc Surg 2008;135:1353-1361
© 2008 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Improving outcomes with long-term "destination" therapy using left ventricular assist devices

James W. Long, MD, PhDa,*, Aaron H. Healy, BSa, Brad Y. Rasmusson, MDa, Cris G. Cowley, MDa, Karl E. Nelson, RN, MBAa, Abdallah G. Kfoury, MDa, Stephen E. Clayson, MDa, Bruce B. Reid, MDa, Stephanie A. Moore, MDb, Douglas U. Blank, MDc, Dale G. Renlund, MDa

a Utah Artificial Heart Program, LDS Hospital, Salt Lake City, Utah
b Massachusetts General Hospital, Boston, Mass
c Idaho Heart Institute, Idaho Falls, Idaho

Presented at the 31st Annual Meeting of the Western Thoracic Surgical Association, June 22–25, 2005, Victoria Conference Center and Fairmount Empress Hotel, Victoria, BC, Canada.

Received for publication April 3, 2006; revisions received August 16, 2006; accepted for publication September 5, 2006.

* Address for reprints: James W. Long, MD, PhD, Utah Artificial Heart Program, 8th Avenue and C Street, Salt Lake City, UT 84143. (Email: jimlong{at}ihc.com).

Objective: Destination therapy experience using long-term left ventricular assist devices was analyzed relative to the benchmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial to evaluate the potential for improving outcomes with this groundbreaking therapy for advanced heart failure.

Methods: The largest single-center experience with destination therapy in the United States (Utah Artificial Heart Program, LDS Hospital, Salt Lake City, UT) was retrospectively analyzed. All destination therapy recipients (n = 23) presented with chronic, advanced heart failure, meeting indications for destination therapy adopted from the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial. All received HeartMate left ventricular assist devices (Thoratec Corp, Pleasanton, Calif), with 87% receiving an improved XVE model. Advanced practice guidelines were implemented using a multidisciplinary approach. Survivals (Kaplan–Meier, log-rank analyses) and adverse events (Poisson regression) were compared with those of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure left ventricular assist device group (n = 68).

Results: Survival in the destination therapy group was significantly increased (P = .007), with an overall reduction in mortality of 66%. The 2-year survival was 77% for destination therapy compared with 29% for the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure left ventricular assist device group (P < .0001). The 1-year survival was 77% for destination therapy compared with the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure left ventricular assist device rate of 52% (P = .036). Adverse events decreased by 38% (3.90 per patient-year in the destination therapy group compared with the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure left ventricular assist device rate of 6.32). Factors related to severity of illness met Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure-like criteria for both groups.

Conclusions: This analysis provides evidence that long-term destination therapy can be improved well beyond the pioneering experience of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial. With continued evolution of devices, management, and patient selection, outcomes approaching those of heart transplantation may be possible.

Abbreviations and Acronyms CVA = cerebrovascular accident; DT = destination therapy; LVAD = left ventricular assist device; OMM = optimal medical management; MCS = mechanical circulatory support; REMATCH = Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure; VO2 max = maximum oxygen consumption


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J. Thorac. Cardiovasc. Surg. 2008 135: 1360-1361. [Extract] [Full Text] [PDF]





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