Implantable ventricular assist devices: is it time to introduce them in Canada?
BACKGROUND
Implantable left ventricular assist devices (LVAD) are increasingly used in Europe and the United States. Any decision to use them in Canada requires estimates of their clinical value and costs.


METHODS
No randomized controlled trials are available. Clinical value and costs, concerning principally the HeartMate and Novacor devices, were estimated based on reports of uncontrolled case series obtained through MEDLINE (1993 to 1999), review articles, three technology assessments and data supplied by the manufacturers.


CONCLUSIONS
Reasonably trouble-free device function can be expected for three to four years. The principal application is as a bridge to transplantation. Rarely, the heart recovers without transplantation. Use as 'permanent' support of the failing heart is still contentious. Approximately 70% of patients with an implanted LVAD survive until recovery or transplantation. Complications are hemorrhage, principally postoperative, 20% to 44%; thromboembolism, ranging from 5% to 15% for the HeartMate to 12% to 37% for Novacor; and significant infection, 50%. Quality of life is slightly inferior to that of patients with transplanted hearts. The direct cost to the health care system of installation is approximately $138,000. As a bridge to transplantation, the estimated cost effectiveness of elective interventions is $91,000 to $126,000 per life-year saved ($117,000 to $186,000, discounted at 5%), and as a permanent alternative to transplantation, the cost per life-year is $52,000 to $60,000 ($50, 000 to $58,000, discounted at 5%), according to circumstances. As a bridge to 50 transplantations per year, the approximate annual cost would be $7 to $13 million (exclusive of transplantation costs). As 'permanent' support for 7000 patients per year, the approximate cost would be $2,661 million per year.


CONCLUSIONS
Limited application in a limited number of centres with collection of all data is justifiable at this stage.
McGregor
M
M
Royal Victoria Hospital, Montreal, Canada. mcre@musica.mcgill.ca
D000328:Adult; D002170:Canada; D003362:Cost-Benefit Analysis; D004638:Emergency Treatment; D004992:Ethics, Medical; D017048:Health Care Costs / Q000706:statistics & numerical data*; D016027:Heart Transplantation; D006353:Heart-Assist Devices / Q000009:adverse effects / Q000191:economics*; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D016459:Prosthesis-Related Infections / Q000209:etiology; D011788:Quality of Life; D012941:Social Responsibility; D013923:Thromboembolism / Q000209:etiology; D018487:Ventricular Dysfunction, Left / Q000191:economics* / Q000628:therapy*