Destination therapy: An alternative for end-stage heart failure patients not eligible for heart transplantation

Purpose of review: Evidence on survival and quality-of-life benefit from destination mechanical circulatory support has been available since the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial and the database of the International Society of Heart and Lung Transplantation is continuously providing information on outcomes. Limited survival, resource allocation, and expanding indications should prompt careful identification of patients most likely to benefit and list program requirements to reconcile patient outcomes with a public health rationale. Recent findings: Suitable candidates should be identified early and referred to centers experienced in all aspects of terminal heart failure care. Extensive studies on pulsatile and nonpulsatile devices are needed, including randomized clinical trials. Coagulopathies are still common early after device implantation whereas infections increase linearly, limiting 1-year survival. Right-sided heart failure should be identified and accurately evaluated, especially in the older population. Arrhythmias unlikely complicate outcomes and improvements in device design can reduce device-related complications. Summary: Indication for destination mechanical circulatory support devices is rapidly increasing and benefit will most likely be obtained if evaluation is systematic and complications are foreseen. Assessment and prediction of organ dysfunction recovery are challenging and several new innovative risk tools might help aid clinical algorithms. Advanced age, renal failure, and right-sided heart failure are related to worst survival, and first consensus guidelines for evaluation and decision-making algorithms have been outlined. Innovative translational medical research, including use of high-throughput genomics, will potentially improve patient selection and might ensure a better survival.