Cardiac transplantation and ventricular assist devices

Achieving 85% hospital discharge and 50% 10-year survival cardiac transplantation has proven benefit for terminally ill patients (Status I) with refractory heart failure. Randomized clinical trials are needed to assess benefit for ambulatory (Status II) patients. Donor hearts are a scarce commodity −120/annum in the UK for 12,000 Stage D candidates <65 years. Patient selection is a complex process. Comorbidity precludes acceptance. Meanwhile mechanical blood pump bio-engineering is a major success story. The observation that pulse pressure is of limited functional importance (compared with flow) has allowed the development of miniaturized continuous-flow devices for long-term use. Meanwhile unloading (resting) the deteriorating LV has been shown to reverse many cellular and molecular changes in heart failure promoting improvement in myocardial function. Temporary extracorporeal assist devices are now used to salvage patients with cardiogenic shock after myocardial infarction, with myocarditis and after surgery. Implantable left ventricular assist devices (LVAD) are emerging as an alternative to transplantation with survival out to 7.5 years. For ischaemic cardiomyopathy the combination of LVAD with autologous or allogenic bone marrow stem cells (to improve vascularity) is being tested. Whilst LVADs and myocardial regenerative therapy improve progressively, the balance between transplantation and emerging alternatives remains in flux.