Will permanent LVADs be better than heart transplantation?

Current interest in permanent mechanical support systems has been renewed as a result of the present shortage of human heart donors, and in view of the satisfactory results obtained with their use as a bridge-to- transplant. As the number of donors is unlikely to increase dramatically in the near future, there is an urgent need to develop mechanical alternatives to transplantation. Preliminary data on the use of the implantable electric LVAD as a bridge-to-transplant indicate that the adverse clinical and mechanical events in outpatients are few and do not preclude use of the device on a permanent basis. Except for infections, transplant issues relating to need for endomyocardial biopsies, rejection, malignancies, and graft arteriosclerosis do not apply to LVAD recipients who face important issues relating to device durability, cost, and potential need for concomitant right heart support. This lack of data on long-term durability contrasts with a yearly mortality rate of about 5% after the first year of transplant. With the initiation of clinical trials on the permanent use of the electric LVAD, several design modifications and upgrading of the currently available devices are expected. Completely sealed systems with steadily improving durability will hopefully appear. Inductive coupling techniques under investigation and development appear to be able to transmit energy without damage across the skin. It is anticipated that with more reliable electronic microprocessors, the future generation of implantable LVADs will be smaller, more reliable and longer lasting.