Evolution of Cardiac Assist from Intermediate In-Hospital Support of Chronic Outpatient Care

Abstract

In the current era of cardiac replacement therapy, there remain two viable options; natural replacement with a donor cardiac allograft, or mechanical circulatory support with the total artificial heart or left ventricular assist device (LVAD). At present, transplantation as an option is not available in adequate numbers to appreciably reduce the numbers of patients dying yearly in the United States from end-stage heart disease. The imbalance between donors and recipients in cardiac transplantation has resulted not only from the wide application of transplantation to varied forms of end-stage heart failure, but also from more discriminating donor selection. In the future, transplant candidacy may become more selective as criteria are defined by critical analysis of current databases. Actuarial survival following heart transplant is effectively limited to 30%–40% at 10 years due to the onset of accelerated graft atherosclerosis [1]. Unfortunately, little progress has been made in the management of immunosuppression, a factor which would reduce the incidence of this complication, which is presumed to be, at least in part, due to chronic low-grade rejection. Finally, quality of life in the heart transplant recipient may not be as excellent as once imagined in a population of very select candidates. Complications due to chronic immunosuppressive therapy, such as renal or hepatic dysfunction, osteoporosis, obesity, diabetes mellitus, and hypertension all compound the course of longterm survival.