title: Should eligibility for heart transplantation be a requirement for left ventricular assist device use? Recommendations based on a systematic review.
abstract: Left ventricular assist devices (LVADs) are used in chronic end-stage heart failure as "bridge to transplantation" (BTT) and, more recently, for transplant-ineligible patients as "destination therapy" (DT). We reviewed the evidence on clinical effects and cost-effectiveness of 2 types of continuous-flow LVADs (HeartMate II [HM II] and HeartWare), for BTT and DT patients. We systematically searched the scientific literature (January 2008-June 2012) and identified 14 clinical studies (approximately 2900 HM II and approximately 200 HeartWare patients), and 3 economic evaluations (HM II) using simulation models. Data were, however, limited to 2-3 studies per outcome. We made policy recommendations on the basis of our systematic review. Although complications after implantation are frequent, LVAD therapy is often highly effective across transplantation eligibility status and device, with 1-year survival reaching 86% for BTT and 78% for DT (compared with 25% for medical therapy). Neither BTT nor DT currently meet traditional cost-effectiveness limits in models using historical data, although BTT is standard practice for a limited number of patients in many regions. We found that BTT and DT as implantation strategies tend to be no longer mutually exclusive. We conclude that evidence is sufficient to support LVAD use, regardless of transplantation eligibility status, as long as patients are carefully selected and program infrastructure and budget are adequate. However, evidence gaps, limitations in economic models, and the lack of Canadian data point to the importance of mandatory, systematic monitoring of LVAD use and outcomes.
authors: Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Québec, Canada. Electronic address: lucy.boothroyd@inesss.qc.ca.
authors: Lucy J
authors: LJ
authors: Boothroyd
authors: Laurie J
authors: LJ
authors: Lambert
authors: Georgeta
authors: G
authors: Sas
authors: Jason R
authors: JR
authors: Guertin
authors: Anique
authors: A
authors: Ducharme
authors: Éric
authors: É
authors: Charbonneau
authors: Michel
authors: M
authors: Carrier
authors: Renzo
authors: R
authors: Cecere
authors: Jean E
authors: JE
authors: Morin
authors: Peter
authors: P
authors: Bogaty
mesh_terms: D002170:Canada; D003362:Cost-Benefit Analysis; D004608:Eligibility Determination; D006333:Heart Failure / Q000191:economics / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation / Q000191:economics / Q000401:mortality; D006353:Heart-Assist Devices / Q000191:economics; D006801:Humans; D018579:Patient Selection; D016019:Survival Analysis