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  • Review Article
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Destination therapy: time for real progress

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 477–483 (2008)Cite this article

Abstract

Both prognosis and quality of life are poor for severely symptomatic patients with stage D heart failure, and treatment options are limited. Few individuals are eligible for cardiac transplantation, and ventricular resynchronization therapy provides only marginal benefit in select patients. The aim of this Review is to highlight the promise of blood pumps in this setting. Circulatory support devices were first developed to act as a bridge to recovery in patients who had failed to wean from cardiopulmonary bypass. As blood pumps developed, they were used to support patients with cardiogenic shock until a donor heart became available. Implantable left ventricular assist devices were then shown to relieve heart failure symptoms and prolong life in patients ineligible for transplant. The limitations of first-generation device technology have meant that the development of an 'off the shelf' solution for advanced heart failure has been slow to progress. New rotary blood pumps already show much promise in this regard but have not yet been subject to rigorous clinical trials. Anecdotal evidence from 7.5 years of event-free survival in the first patient to receive a 'destination' axial flow pump permits justifiable optimism about the future of this approach. It is now time for real progress.

Key Points

  • Severely symptomatic (stage D or NYHA class IV) heart failure is an expanding problem, with patients having a poor prognosis and limited treatment options

  • Cardiac allotransplantation does not address the epidemiological problem and lacks a firm evidence base, particularly for ambulatory United Network for Organ Sharing status II candidates

  • Mechanical blood pumps were first developed to sustain life in patients with cardiogenic shock during heart surgery, then were used in selected patients with end-stage heart failure pending acquisition of a donor heart

  • The REMATCH trial provided firm though inauspicious evidence for the use of blood pumps as an alternative to medical therapy in the end-stage heart failure population not eligible for transplant

  • Destination therapy with the new rotary blood pumps provides a promising 'off the shelf' solution to heart failure, but more rigorous, independent, non-industry-sponsored clinical trials are needed to provide a firm evidence base for the use of these devices

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Author notes

  1. John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK stephen.westaby@orh.nhs.uk

Authors and Affiliations

  1. S Westaby is a Consultant Cardiac Surgeon at Oxford Radcliffe NHS Trust, Oxford, and Professor of Biomedical Science, University of Wales, Swansea, UK.,

    Stephen Westaby

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Westaby, S. Destination therapy: time for real progress. Nat Rev Cardiol 5, 477–483 (2008). https://doi.org/10.1038/ncpcardio1255

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