Left ventricular assist device for end-stage heart failure: results of the first LVAD destination program in the Netherlands

Today, heart transplantation is the golden standard for the treatment of patients with end-stage heart failure. A median survival time of more than 11 years (and 13 years for those surviving the first year) after transplantation will be hard to equal let alone to beat [1]. As a result of donor organ shortage, transplantation can, unfortunately, only be offered to a few patients. Supported by considerable improvements in left ventricular assist devices (LVADs) cardiologists and surgeons in the USA, as well as elsewhere in Europe, are eagerly accepting the LVAD as a long-term therapy (destination therapy). Historically, LVADs were used as a bridge to a transplan-tation (BTT) or bridge to recovery in the very few patients whose heart function improved after a period of mechanical support. In less than two decades LVADs have evolved from short-term axial extracorporeal pulsatile devices to smaller intracorporeal continuous flow devices for long-term support. In doing so, the complication rates have dropped considerably and an additional treatment for end-stage heart failure has become a reality, paving the way for LVAD as long-term therapy. Patients who are deemed unfit for transplantation can now be offered an alternative therapy. It is important, however, to realise that the indications of BTT and destination therapy will no longer be mutually exclusive; they may be a moving target. For example, patients on destination therapy may become BTT patients over time due to the fact that a contraindication for transplantation has disappeared: e.g. they have survived their malignancy long enough or their pulmonary pressures have normalised. On the other hand, patients on BTT therapy might become destination therapy patients if they develop a malignancy during the waiting time. The two leading LVAD devices currently on the market are the Heart Mate II and HeartWare. In the United States the Heart Mate II has been approved for BTT since 2008 and as destination therapy since 2010, while HeartWare is approved as BTT since 2010 and is still awaiting approval for destination therapy. During 2012 more than 40 % of all implants in the USA were designated as destination therapy [2]. In Europe, the current Heart Mate II ratio BTT/ destination therapy is 75 %/25 % (information from Thoratec Corp). In the Netherlands, mechanical support by an LVAD is only reimbursed by the Health Insurance Companies when used as a BTT. In a recent consensus document, the Netherlands Society of Cardiology and the …