Cardiac retransplantation and mechanical circulatory support

Abstract

In patients with end-stage heart failure refractory tomedical and cardiac resynchronisation therapy, hearttransplantation is recognised as the treatment ofchoice. As compared to medical therapy, heart transplantationis considered to be associated with a survivalbenefit, to enhance functional capacity and improvequality of life, provided that patients are properlyselected in accordance with guidelines. However, a powerfultrial to compare heart transplantation withconventional management is still lacking and is unlikelyto be performed. Individually tailored anti-rejectionregimens, based on the currently used immunosuppressiveagents, have produced an excellentsurvival rate following heart transplantation. Unlikethe increase in survival in the early phase after transplantation,the attrition rate over the long term has remainedsimilar in recent decades, largely because ofassociated complications such as chronic allograftvasculopathy and malignancy, the incidence of whichcould not be markedly reduced. Since the number ofheart transplantations is limited due to the shortage ofdonor organs, and since, in parallel, the number ofpatients with end-stage heart failure is constantlyincreasing, mechanical circulatory support is gainingin importance. The pulsatile devices originally usedwere associated with a high frequency of adverseevents such as bleeding and thromboembolic events,noisiness and patient discomfort, which preventedwidespread application. The introduction of continuous-flow pumps which are silent and comfortable, andcause fewer side effects, has revolutionised mechanicalcirculatory support. Since survival on such devices hassignificantly improved as compared to the previousera, implant rates have dramaticallyincreased, particularly as analternative to transplantation. Incarefully selected patients the outcomeof destination therapy approachessurvival rates close tothose after heart transplantation.