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Clinical Summary Between January 2000 and September 2004, 15 patients received destination LVAD therapy in our institution. Nine patients had received the Novacor device as part of the INTrEPID (Investigation of Non-Transplant-Eligible Patients who are Inotrope Dependent) trial, and 6 had received the HeartMate XVE device (Thoratec Corporation) after US Food and Drug Administration approval was granted for destination therapy. From this group, 6 patients were reevaluated and listed for transplantation. The mean age was 52 years (range, 31-66 years). The cause of the underlying cardiomyopathy was ischemic in 4 patients, idiopathic in 1 patient, and adriamycin-induced heart failure in 1 patient. Contraindications for cardiac transplantation before LVAD destination therapy were irreversible severe pulmonary hypertension in 5 patients, 2 of whom also had concomitant renal insufficiency and 1 of whom had a recent history of treated endometrial cancer (Table 1). After LVAD implantations, significant reduction in pulmonary arterial pressure, pulmonary vascular resistance, and renal function was seen in these patients (Table 2). Heart transplantation was initially contraindicated in another patient because of psychosocial history and poor compliance. The mean duration of LVAD support until listing among the 6 patients was 243 days (range, 88-684 days). Four patients have undergone transplantation and are alive at a mean duration of 33 months (range, 8-55 months; Table 1). One patient is still on the waiting list, and 1 died from a hemorrhagic cerebrovascular accident before undergoing transplantation. In the one patient with cancer, there has been no evidence of recurrence. None of the patients who underwent transplantation with previous pulmonary hypertension had significant perioperative right ventricular dysfunction. The remaining 9 patients with LVAD destination therapy were not offered heart transplantation because of either the presence of ongoing contraindications to heart transplantation or perioperative death after LVAD implantation. The contraindications to heart transplantation in these 9 patients were significant comorbidity in 3 patients, advanced age in combination with significant comorbidity in 3 patients, and malignancy in 2 patients. At a mean follow-up of 200 days (range, 1-1095 days), 5 patients were deceased, whereas the remaining patients were still alive. The causes of death in the 5 patients were multiorgan failure in 3 patients, traumatic hemorrhagic cerebrovascular accident after a motor vehicle accident in 1 patient, and intraoperative death in 1 patient.

The beneficial role of left ventricular assist device destination therapy in the reversal of contraindications to cardiac transplantation