Continuous-Flow LVAD Therapy: A Successful Alternative for End-Stage Heart Failure

By Sonjoy Laskar, MD, Assistant Professor of Medicine; Center for Heart Failure Therapy, and J. David Vega, MD, Associate Professor of Surgery; Director, Heart Transplant and VAD Programs, Emory University Hospital

Despite advances in the treatment of congestive heart failure, the survival of patients with end-stage disease remains quite dismal. Patients who are unable to be weaned from inotropic support by definition have a very poor survival rate; patients receiving continuous palliative inotropes have a six-month mortality rate between 60 percent and 75 percent.1 Additional negative prognostic risk factors include repeated hospitalizations for volume overload, repeated episodes of ventricular tachycardia and worsening renal insufficiency due to cardiac causes. However, no definitive clinical risk score has been developed to identify end-stage heart failure. This is an active area of clinical investigation at Emory under the direction of Javed Butler, MD.

While transplantation is definitive therapy for end-stage heart failure,2 the number of cardiac transplants performed in the U.S. each year is limited to approximately 2,200 due to donor availability.3 Left ventricular assist devices (LVADs) are a type of mechanical circulatory support device that have been in use for more than 25 years primarily in patients with refractory heart failure who are awaiting transplantation.4 Emory University Hospital has been at the forefront of VAD therapy, implanting our first device in 1988 and more than 65 devices since then.

LVAD as “destination therapy” for patients with end-stage heart failure who were ineligible for transplantation was investigated in the REMATCH trial, a prospective, randomized study of LVADs versus medical therapy.5 In this landmark study, the two-year survival rate was significantly better for patients receiving an LVAD compared to those receiving medical therapy alone (24 percent vs. 8 percent). Based on these results, in 2003, the HeartMate XVE® pulsatile LVAD (Thoratec Corporation, Pleasanton, Calif., U.S.) became the first device to be approved by the U.S. Food and Drug Administration (FDA) for destination therapy in end-stage heart failure.6

Emory’s VAD program implanted our first device as destination therapy in 2006 in a patient who was inotrope-dependent but who was not a candidate for heart transplantation.