By Guy MacGowan
Each year, fewer than 1,000 hearts are available across Europe for transplant1. This does not bode well for the estimated 750,000 patients with heart failure (or the 27,000 who are diagnosed each year)2 in the UK alone. There are alternative (potentially life-saving) options to heart transplantation, such as left ventricular assist devices, but patients are rarely referred to the centres that can evaluate them to see if they would be suitable for one of these options. For example, the UK’s six transplant hospitals implant fewer than 100 left ventricular assistant devices per year3.
To match the proportion of people with heart failure who receive such a device in the USA (which has about the same percentage of population in heart failure and outpaces the number of UK heart transplants by almost 20-to-1)4, the UK would need to increase its implantation rate of left ventricular devices by 300%.
This low use of left ventricular assist device in the UK occurs despite the fact that the European Society of Cardiology (ESC) recommends these devices for patients who have end-stage heart failure who are receiving optimal treatment, and who are suitable for heart transplantation5. The ESC also recommends left ventricular assist devices for end-stage heart failure patients who are not suitable for a heart transplant but are expected to die within a year5.
Why more patients with heart failure are not referred for further evaluation in the UK is not always clear. One reason may be that physicians believe that medical management is the only option available given the limited number of hearts available for transplant. Another reason might be that they believe left ventricular assist devices are untested or that the NHS will not fund surgical procedures to implant the devices.
However these devices have now been used for several decades and have been steadily
improving—particularly with more recent developments.
The latest innovations in device technology have made them simpler, smarter and more versatile. Recent data show that survival with a next generation device is 93% at 180 days and 90% at one year6.
By comparison, survival in patients with severe heart failure on medical management alone with Seattle Heart Failure Model has been estimated to be 73% at 180 days and 58% at one year7. Furthermore, the NHS does fund implantation of left ventricular assist devices.
It should be noted that left ventricular assistant devices are not without risk or drawbacks. Patients can face complications, such as clots and infections, have to be on medication for life, and have to be willing and able to endure ongoing maintenance. But, the benefits of implanting such a device (ie. preventing premature death) could be said to outweigh these risks.
Therefore, physicians need greater awareness of the benefits of left ventricular assist devices so that they can refer advanced heart failure patients for further evaluation to transplant centres and, potentially, enable their patient to receive a life-saving treatment.
1. Stehlik J, et al. Heart Lung Transplant 2010; 29: 1089–103
2. Heart Research Institute. www.hriuk.org/about-heart-disease/heart-facts
3. Emin et al, European Journal of Heart Failure (2013) 15, 1185–1193
4. Organ Procurement and Transplantation Network.
5. European Society of Cardiology. http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/acute-chronic-heart-failure-2012.aspx.
6. Aaronson et al. Circulation 2012; 125: 3191–200
7. Strueber et al. J Am Coll Cardiol 2011; 57(12): 1375–82
Guy MacGowan is a cardiologist at Freeman Hospital in Newcastle upon Tyne, UK. He has no conflicts of interests relating to left ventricular assist devices