Contributed by Ranjit John, MD
Patients with severe heart failure with inotrope-dependence typically can be candidates for heart transplantation1; however, heart failure often presents with other complicating conditions, which can alter a patient’s overall prognosis. Access to suitable donor organs can also delay transplant procedures. In such cases, implanted mechanical circulatory devices can serve as a bridge to transplant or as destination therapy.1
A 64-year-old patient was referred to the University of Minnesota Health Heart Care physicians with a diagnosis of congestive heart failure. He was being treated intravenously with the cardiac inotrope dobutamine. Echocardiography and right heart catheterization to measure pressures in the patient’s heart provided confirmation of decompensated congestive heart failure with inotrope dependence. The patient was also found to have severe tricuspid regurgitation. Damage to the heart occurred likely as a result of chemotherapy for lymphoma, which was administered more than 5 years prior to the diagnosis of congestive heart failure. He was also in need of treatment for chronic renal failure.
A team of specialists considered the patient’s kidney disease and prior cancer treatment along with his heart condition and concluded that his comorbidities were manageable, making him a candidate to receive a surgically implantable left ventricle assist device (LVAD). The patient was entered in the Momentum 3 clinical trial to receive the HeartMate 3 (St. Jude Medical) as a bridge to a transplant2 and concomitant tricuspid valve repair. The specialists explained that the valve repair and device placement could be carried out in the same surgical procedure. The patient agreed to the procedure and participation in the clinical trial.
Following implantation of the HeartMate 3 LVAD and valve repair, the patient remained stable and experienced no complications as a result of treatment. At this point, owing to his relatively young age and stability of symptoms, he was considered a strong candidate for a heart transplant. Within 8 months, he received a heart transplant followed by cardiac rehabilitation.
In patients at high risk of sudden death from acute heart failure, an LVAD can serve as bridge to further treatment or as the therapy itself. The LVAD provides patients heart support until they can receive a transplant; in some patients, it can become a long-term treatment, referred to as destination therapy. Still others may achieve full recovery through placement of an LVAD and experience eventual independence from the device.1
In this case, the LVAD served as a temporary solution that provided a bridge to transplant — the best long-term solution for the patient. Nearly 2 years later, he remains free of any symptoms of heart failure.
Left ventricular assist devices have emerged as a viable heart-failure treatment or bridge to transplant. The latest LVADs seek to reduce the risk of thrombosis and further improve outcomes.Continue reading