Assist devices a viable alternative to heart transplant

Jacob Abraham, M.D.
Medical director, Providence Ventricular Assist Device Program
Gary Ott, M.D.
Surgical director, Providence Ventricular Assist Device Program

Published June 2012

Some patients aren’t candidates for a heart transplant. Others are too ill to wait for a donor heart. For them the best – and sometimes the only – option is an implanted ventricular assist device, or VAD. Mechanical circulatory support with a VAD has improved survival and quality of life in select patients with medically-refractory heart failure. Recent results with the HeartMate II, for example, show a 90 percent one-year survival among transplant-eligible patients, which is comparable to survival with transplant.

Providence St. Vincent Medical Center, part of Providence Center for Advanced Heart Disease, is a Joint Commission-certified destination for VAD, a therapy that has improved survival and quality of life for thousands of patients worldwide.
 
Determining eligibility
Selecting the right patient and the right time for surgery are key to good outcomes. Patients with systolic heart failure (ejection fraction under 30 percent) should have one or more of the following to qualify for VAD therapy:

  • Class III-IV symptoms
  • Inability to tolerate oral drug therapy
  • Hospitalization for heart failure within the past six months
  • Early end-organ dysfunction (renal or hepatic)
  • Onset of cardiac cachexia
  • Considered for or on inotropic therapy
  • Ventricular arrhythmias or defibrillator shocks
  • Unresponsive to cardiac resynchronization therapy, or CRT is not indicated
  • Hyponatremia

On the other hand, patients are not good candidates if they have severe and irreversible end-organ dysfunction (e.g., hemodialysis, oxygen-dependent lung disease, cirrhosis) or another illness that limits their life expectancy to fewer than two years. Likewise, patients who are frail, suffer neurologic impairment or are at high risk for bleeding are unlikely to benefit from VAD therapy.

Excellent outcomes have been achieved in carefully selected elderly patients. While there is no absolute age cutoff for VAD therapy, candidates 75 or younger are usually appropriate for destination therapy. All patients must have adequate psychosocial support and a stable home environment.

After implantation
Most patients spend two to three weeks in the hospital before discharge. Once out of the intensive care unit – usually after four to seven days – patients will receive intense physical and occupational therapy.

Our VAD coordinators and nurses educate patients and their loved ones on living with a ventricular assist device. This not only involves caring for the driveline and changing dressings, but learning new habits, such as carrying spare batteries and avoiding total immersion in water.

After hospital discharge, patients are seen weekly in Providence Center for Advanced Heart Disease. Additional follow-up visits are scheduled based on the patient's progress. Most patients feel dramatically better within weeks of surgery and have sustained improvements in functional class and end-organ function.

FAQs about the HeartMate II VAD

Clinical articles by Jacob Abraham, M.D.