Ventricular assistance to bridge to transplantation

Regression of pathological cardiac hypertrophy: signaling pathways and therapeutic targets

Pathological cardiac hypertrophy is a key risk factor for heart failure. It is associated with increased interstitial fibrosis, cell death and cardiac dysfunction. The progression of pathological cardiac hypertrophy has long been considered as irreversible. However, recent clinical observations and experimental studies have produced evidence showing the reversal of pathological cardiac hypertrophy. Left ventricle assist devices used in heart failure patients for bridging to transplantation not only improve peripheral circulation but also often cause reverse remodeling of the geometry and recovery of the function of the heart. Dietary supplementation with physiologically relevant levels of copper can reverse pathological cardiac hypertrophy in mice. Angiogenesis is essential and vascular endothelial growth factor (VEGF) is a constitutive factor for the regression. The action of VEGF is mediated by VEGF receptor-1, whose activation is linked to cyclic GMP-dependent protein kinase-1 (PKG-1) signaling pathways, and inhibition of cyclic GMP degradation leads to regression of pathological cardiac hypertrophy. Most of these pathways are regulated by hypoxia-inducible factor. Potential therapeutic targets for promoting the regression include: promotion of angiogenesis, selective enhancement of VEGF receptor-1 signaling pathways, stimulation of PKG-1 pathways, and sustention of hypoxia-inducible factor transcriptional activity. More exciting insights into the regression of pathological cardiac hypertrophy are emerging. The time of translating the concept of regression of pathological cardiac hypertrophy to clinical practice is coming.

Clinical and cost-effectiveness of left ventricular assist devices as destination therapy for people with end-stage heart failure: A systematic review and economic evaluation

Objectives: The clinical and cost-effectiveness of left ventricular assist devices as destination therapy for people with end-stage heart failure is assessed through a systematic review and economic evaluation.

Methods: Systematic review was performed of randomized controlled trials, quasiexperimental studies, case series, and case studies identified through searching eighteen electronic databases, bibliographies, and consultation with experts and manufacturers. Studies assessed survival, functional capacity, and quality of life. Cost-effectiveness was assessed through a 5-year decision analytic model to estimate the incremental cost-effectiveness ratio for using left ventricular assist devices compared with usual care.

Results: Six studies met the inclusion criteria, showing that left ventricular assist devices appear beneficial, improving survival and quality of life. Adverse events are a serious concern. The economic evaluation showed that left ventricular assist devices had a cost per quality adjusted life year of £170,616. Sensitivity analysis showed that the cost-effectiveness was not sensitive to changes in costs or utility.

Conclusions: Although left ventricular assist devices appear clinically effective as destination therapy, it is unlikely they will be cost-effective unless costs decrease or the benefits of their use increase.

Clinical and cost-effectiveness of left ventricular assist devices as a bridge to heart transplantation for people with end-stage heart failure: a systematic review and economic evaluation

AIMS

To evaluate the clinical and cost-effectiveness of left ventricular (LV) assist devices (LVADs) as a bridge to transplant (BTT) for people with end-stage heart failure (ESHF) through a systematic review and economic evaluation.

METHODS AND RESULTS

The systematic review and economic evaluation was conducted according to internationally recognized methods. The search strategy identified systematic reviews, randomized controlled trials, quasi-experimental studies, and observational studies evaluating the effects of LVADs on survival, functional capacity, and quality of life. Cost-effectiveness was assessed through a 5-year decision analytic model to estimate the incremental cost-effectiveness ratio of LVADs compared with usual care. Despite the poor methodological quality of the 18 studies included, LVADs appear beneficial improving survival, functional status, and quality of life. Adverse events are a serious concern. The economic evaluation showed that LVADs had a cost per quality adjusted life year of pound 65,242 (95% confidence interval pound 34,194-364,564). Sensitivity analysis showed that post-heart transplant survival gains, pre-heart transplant patient utility, and one-off costs associated with implantation determine cost-effectiveness.

CONCLUSION

Although LVADs appear clinically effective as a BTT for people with ESHF, it is unlikely that they will be cost-effective unless costs decrease or the benefits of their use increase.