Skip to main content
SpringerLink
Log in

Ventricular assist device therapy and heart transplantation: Benefits, drawbacks, and outlook

Mechanische Herzunterstützung und Herztransplantation: Möglichkeiten, Limitationen und Perspektiven

  • Main topic
  • Published:
Herz Aims and scope Submit manuscript

Abstract

End-stage heart failure is associated with significant morbidity and mortality. Heart transplantation has the potential to offer a return to daily activities for critically ill patients and is the gold standard therapy. However, heart transplantations are decreasing yearly with a historic low in Germany in 2017. By striking contrast, both waiting list numbers and waiting time have increased owing to a lack of acceptable donor organs. Ventricular assist devices (VAD) represent a reasonable therapeutic alternative for patients on heart transplantation waiting lists. Patients ineligible for transplantation may undergo VAD implantation as a destination therapy. However, the necessity for life-long anticoagulation must be weighed against bleeding complications in potential VAD candidates. VAD-dependent patients also face risks of driveline infections, in addition to restricted activities of daily living owing to limited battery capacities. Given Germany’s low transplantation rate, VAD implantation may serve as a middle ground. With the recent events in transplantation medicine, trust among the German population has declined. Transplant centers must ensure graft quality and ongoing care, define minimum caseload for accreditation, and implement specialty care units in heart failure. Furthermore, the legislation shift from extended consent to dissent solution has the potential to end donor organ shortage.

Zusammenfassung

Ein terminales Herzversagen ist mit einer hohen Morbidität und Mortalität assoziiert. Eine Herztransplantation bietet eine adäquate Therapie, kann die Lebensqualität der Patienten wiederherstellen und ist nach wie vor der Goldstandard. Die Anzahl der Transplantationen sinkt jedoch jährlich mit einem historischen Tiefpunkt in Deutschland im Jahr 2017. Dagegen steigen die Anzahl der Patienten auf der Warteliste und die Wartezeit aufgrund des zunehmenden Mangels an akzeptablen Spenderorganen. Mechanische Herzunterstützungssysteme bieten eine Alternative für Patienten auf der Warteliste. Patienten, welche nicht für eine Herztransplantation infrage kommen, können im Sinne einer endgültigen Therapie („destination therapy“) hiermit ebenfalls eine akzeptable Lebensqualität zurückerhalten. Diese Systeme benötigen jedoch eine dauerhafte Antikoagulation, um Embolien zu vermeiden. Dadurch sind die Patienten durch Blutungskomplikationen und Infektionen an der Austrittsstelle des Verbindungskabels bedroht. Der Alltag wird zudem durch die Haltbarkeit der Batterien begrenzt. Aufgrund der jährlich sinkenden Spender- und somit auch Transplantationszahlen besteht jetzt Handlungsbedarf. Seit dem Transplantationsskandal ist das Vertrauen der Bevölkerung in Deutschland gesunken. Eine Umstrukturierung der Transplantationszentren zur Verbesserung der Qualität und der Überlebensrate der Herztransplantation ist notwendig. Hierzu zählen die Etablierung von Herzinsuffizienzstationen sowie die Definition von Mindestzahlen für Transplantationen. Darüber hinaus könnte eine Änderung der Gesetzeslage weg von der erweiterten Zustimmungslösung und hin zur Widerspruchslösung die Organknappheit beseitigen.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

References

  1. Alba AC, Rao V, Ivanov J et al (2009) Usefulness of the INTERMACS scale to predict outcomes after mechanical assist device implantation. J Heart Lung Transplant 28:827–833

    Article  PubMed  Google Scholar 

  2. Ardehali A, Esmailian F, Deng M et al (2015) Ex-vivo perfusion of donor hearts for human heart transplantation (PROCEED II): a prospective, open-label, multicentre, randomised non-inferiority trial. Lancet 385:2577–2584

    Article  PubMed  Google Scholar 

  3. Barnard CN (1967) The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town. S Afr Med J 41:1271–1274

    PubMed  CAS  Google Scholar 

  4. Bauer A, Postrach J, Thormann M et al (2010) First experience with heterotopic thoracic pig-to-baboon cardiac xenotransplantation. Xenotransplantation 17:243–249

    Article  PubMed  Google Scholar 

  5. Beckmann A, Funkat AK, Lewandowski J et al (2017) German Heart Surgery Report 2016: the annual updated registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 65:505–518

    Article  PubMed  Google Scholar 

  6. Brenner P, Reichart B, Mayr T et al (2018) Worldwide first successful long-term survival after orthotopic cardiac xenotransplantation of multitransgenic pig hearts into baboons using a CD40mAb or CD40L Costimulation blockade. Thorac Cardiovasc Surg 66(S 01):S1–S110

    Google Scholar 

  7. Claes S, Berchtold-Herz M, Zhou Q et al (2017) Towards a cardiac allocation score: a retrospective calculation for 73 patients from a German transplant center. J Cardiothorac Surg 12:14

    Article  PubMed  PubMed Central  Google Scholar 

  8. Cohn WE, Timms DL, Frazier OH (2015) Total artificial hearts: past, present, and future. Nat Rev Cardiol 12:609–617

    Article  PubMed  Google Scholar 

  9. Cooper DK, Koren E, Oriol R (1993) Genetically engineered pigs. Lancet 342:682–683

    Article  PubMed  CAS  Google Scholar 

  10. Cooper DK, Keogh AM, Brink J et al (2000) Report of the Xenotransplantation Advisory Committee of the International Society for Heart and Lung Transplantation: the present status of xenotransplantation and its potential role in the treatment of end-stage cardiac and pulmonary diseases. J Heart Lung Transpl 19:1125–1165

    Article  CAS  Google Scholar 

  11. Cooper DK, Ekser B, Ramsoondar J et al (2016) The role of genetically engineered pigs in xenotransplantation research. J Pathol 238:288–299

    Article  PubMed  Google Scholar 

  12. Deutsche Stiftung Organtransplantation (2017) Bundesweite Grafiken zur Organspende 2017. DOT_2017_14_97_Indikationen_HerzTX.jpg. https://www.dso.de/dso-news-home/galerie-jahresbericht-2017.html. Accessed 11 Jan 2018

  13. Deutsche Stiftung Organtransplantation (2017) Herztransplantation. Grafiken. https://www.dso.de/organspende-und-transplantation/transplantation/herztransplantation.html. Accessed 11 Jan 2018

  14. Eurotransplant (2016) Annual report. https://www.eurotransplant.org/cms/mediaobject.php?file=Eurotransplant+JV+PDF.pdf. Accessed 11 Jan 2018

    Google Scholar 

  15. Eurotransplant (2018) Eurotransplant statistics. http://statistics.eurotransplant.org/index.php?search_type=donors&search_organ=&search_region=All+ET&search_period=by+year&search_characteristic=&search_text=tp://statistics.eurotransplant.org : 1032P_All ET. Accessed 11 Jan 2018

    Google Scholar 

  16. Grady KL, Naftel DC, Kobashigawa J et al (2007) Patterns and predictors of quality of life at 5 to 10 years after heart transplantation. J Heart Lung Transplant 26:535–543

    Article  PubMed  PubMed Central  Google Scholar 

  17. Hirt MN, Hansen A, Eschenhagen T (2014) Circ Res 114:354–367

    Article  PubMed  CAS  Google Scholar 

  18. IQTIG (2016) Qualitätsreport. https://www.dgthg.de/upload/IQTIG_Qualitaetsreport-2016.pdf. Accessed 11 Jan 2018

    Google Scholar 

  19. ISHLT (2018) Transplant registry quarterly reports. https://www.ishlt.org/registries/quarterlyDataReportResults.asp?organ=HR&rptType=all&continent=3. Accessed 11 Jan 2018

    Google Scholar 

  20. Kirklin J, Collum C, Timkovich N et al (2017) Intermacs quarterly statistical report 2017 Q3. https://www.uab.edu/medicine/intermacs/images/Federal_Quarterly_Report/Federal_Partners_Report_2017_Q3.pdf. Accessed 11 Jan 2018

    Google Scholar 

  21. Kobashigawa JA, Miller LW, Russell SD et al (2006) Tacrolimus with mycophenolate mofetil (MMF) or sirolimus vs. cyclosporine with MMF in cardiac transplant patients: 1‑year report. Am J Transplant 6:1377–1386

    Article  PubMed  CAS  Google Scholar 

  22. Kuwaki K, Knosalla C, Dor FJ et al (2004) Suppression of natural and elicited antibodies in pig-to-baboon heart transplantation using a human anti-human CD154 mAb-based regimen. Am J Transplant 4:363–372

    Article  PubMed  CAS  Google Scholar 

  23. Liotta D, Hall CW, Henly WS et al (1963) Prolonged assisted criculation during and after cariac or aortic surgery. Prolonged partial left ventricular bypass by means of intracorporeal circulation. Am J Cardiol 12:399–405

    Article  PubMed  CAS  Google Scholar 

  24. Lund LH, Edwards LB, Kucheryavaya AY et al (2013) The registry of the international society for heart and lung transplantation: thirtieth official adult heart transplant report-2013; focus theme: age. TJ Heart Lung Transpl 32:951–964

    Article  Google Scholar 

  25. Lund LH, Edwards LB, Dipchand AI et al (2016) The registry of the international society for heart and lung transplantation: thirty-third adult heart transplantation report-2016; focus theme: primary diagnostic indications for transplant. J Heart Lung Transplant 35:1158–1169

    Article  PubMed  Google Scholar 

  26. Mamas MA, Sperrin M, Watson MC et al (2017) Do patients have worse outcomes in heart failure than in cancer? A primary care-based cohort study with 10-year follow-up in Scotland. Eur J Heart Fail 19:1095–1104

    Article  PubMed  Google Scholar 

  27. Matesanz R, Dominguez-Gil B, Coll E et al (2017) How Spain reached 40 deceased organ donors per million population. Am J Transplant 17:1447–1454

    Article  PubMed  CAS  Google Scholar 

  28. Mcgregor CGA, Byrne GW (2017) Porcine to human heart transplantation: is clinical application now appropriate? J Immunol Res 2017:2534653

    Article  PubMed  PubMed Central  Google Scholar 

  29. Mikus E, Stepanenko A, Krabatsch T et al (2011) Reversibility of fixed pulmonary hypertension in left ventricular assist device support recipients. Eur J Cardiothorac Surg 40:971–977

    PubMed  Google Scholar 

  30. Mohiuddin MM, Reichart B, Byrne GW et al (2015) Current status of pig heart xenotransplantation. Int J Surg 23:234–239

    Article  PubMed  PubMed Central  Google Scholar 

  31. Mohiuddin MM, Singh AK, Corcoran PC et al (2016) Chimeric 2C10R4 anti-CD40 antibody therapy is critical for long-term survival of GTKO.hCD46.hTBM pig-to-primate cardiac xenograft. Nat Commun 7:11138

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  32. Monteagudo Vela M, Garcia Saez D, Simon AR (2018) Current approaches in retrieval and heart preservation. Ann Cardiothorac Surg 7:67–74

    Article  PubMed  PubMed Central  Google Scholar 

  33. Murali S, Kormos RL, Uretsky BF et al (1993) Preoperative pulmonary hemodynamics and early mortality after orthotopic cardiac transplantation: the Pittsburgh experience. Am Heart J 126:896–904

    Article  PubMed  CAS  Google Scholar 

  34. Page A, Messer S, Large SR (2018) Heart transplantation from donation after circulatory determined death. Ann Cardiothorac Surg 7:75–81

    Article  PubMed  PubMed Central  Google Scholar 

  35. Phelps CJ, Koike C, Vaught TD et al (2003) Production of alpha 1,3-galactosyltransferase-deficient pigs. Science 299:411–414

    Article  PubMed  CAS  Google Scholar 

  36. Poglajen G, Vrtovec B (2015) Stem cell therapy for chronic heart failure. Curr Opin Cardiol 30:301–310

    Article  PubMed  Google Scholar 

  37. Reitz BA, Bieber CP, Raney AA et al (1981) Orthotopic heart and combined heart and lung transplantation with cyclosporin—a immune suppression. Transplant Proc 13:393–396

    PubMed  CAS  Google Scholar 

  38. Smits J (2014) Eurotranplant manual, chapter 6—ET thoracic allocation system (EthAS). https://www.eurotransplant.org/cms/mediaobject.php?file=Chapter6_Thoracic13.pdf. Accessed 11 Jan 2018

    Google Scholar 

  39. Stewart S, Winters GL, Fishbein MC et al (2005) Revision of the 1990 working formulation for the standardization of nomenclature in the diagnosis of heart rejection. J Heart Lung Transplant 24:1710–1720

    Article  PubMed  Google Scholar 

  40. Vakil K, Duval S, Sharma A et al (2014) Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: a UNOS registry analysis. Int J Cardiol 176:595–599

    Article  PubMed  Google Scholar 

  41. Wang JX, Smith JR, Bonde P (2014) Energy transmission and power sources for mechanical circulatory support devices to achieve total implantability. Ann Thorac Surg 97:1467–1474

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiac Surgery, Klinikum der Universität München, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377, Munich, Germany

    S. Buchholz, S. P. W. Guenther, S. Michel, R. Schramm & C. Hagl

Authors
  1. S. Buchholz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. P. W. Guenther
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. Michel
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. R. Schramm
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C. Hagl
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. Hagl.

Ethics declarations

Conflict of interest

S. Buchholz, S.P.W. Guenther, S. Michel, R. Schramm, and C. Hagl declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Buchholz, S., Guenther, S.P.W., Michel, S. et al. Ventricular assist device therapy and heart transplantation: Benefits, drawbacks, and outlook. Herz 43, 406–414 (2018). https://doi.org/10.1007/s00059-018-4713-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00059-018-4713-3

Keywords

Schlüsselwörter

Search

Navigation