Cost of ventricular assist devices: can we afford the progress?

T he societal cost of heart failure (HF) is matched by few other medical conditions. More than 670 000 new cases will be diagnosed this year. 1 It commonly affects the aged and is associated with other chronic illnesses. Despite significant improvements in outcomes associated with contemporary medical and electric therapies, HF tends to be a progressive condition with a median survival of only 2 to 3 years after diagnosis. 2 In addition, HF is the second most costly condition for Medicare. 3 The total expenditure on this disease in the United States is estimated between $20 to $39 billion, 1,4,5 which corresponds to 1.5% to 4% of total health care costs. 6 Further, the majority of medical financial resources are consumed in the final 2 years of life, a cost estimated at nearly $155 000. 7 Patients with advanced HF failing optimal treatments have limited therapeutic options. A small subset may qualify for cardiac transplantation, but stringent candidacy criteria and a limited supply of donor hearts limits its value to the larger HF population. In the past 5 years, improvements in left ventricu-lar assist devices (LVAD) have made this a viable option to bridge a patient to transplant (BTT) or as permanent therapy (Destination Therapy, DT). The inability to define the size of the population that may ultimately be candidates for VAD therapy, particularly as DT, has led to widespread angst about the health care cost implications of this technology. The primary focus of this article is to critically review the available literature on the cost of VADs as well as alternative treatments for advanced HF. Patients with advanced HF have a 1-year survival of only 10% to 25%. 8 Initial clinical trials of older pulsatile flow LVADs used as destination therapy demonstrated 1-year survival of 52%, 9 and more recent studies of continuous flow pumps, used for the same indication, showed 1-year survival of 73%. 10 These studies also documented improvements in func-tionality and quality of life relative to that seen with medically-treated HF. With the observed gains in longevity, functionality, and quality of life in destination VAD recipients, mechanical circulatory support compares favorably with heart transplanta-tion, the only long-term solution for patients with end-stage HF just a decade ago. Better technology with better outcomes and fewer adverse events, as well as smaller devices fitting into more patients, has prompted growth in the number of LVAD implants and …