This post was authored by former ACC President Alfred Bove, MD, PhD, MACC.
Recently, the Wall Street Journal profiled former vice president Dick Cheney’s 33-year battle with heart disease. Cheney has had five heart attacks and had a left ventricular assist device (LVAD) implanted a year ago. Cheney’s medical history is a fascinating story of the combination of technology and perseverance. Quite simply, he owes his life to cardiovascular innovation.
It’s hard to believe the advances we have seen in the last 60 years. As Cheney recounts in WSJ, life-saving techniques for MI back in the 1950s were limited, something he experienced first-hand with the death of his grandfather from a heart attack. Unlike his grandfather though, the vice president has received numerous cutting-edge procedures throughout the years that have kept him alive and working in Washington, up until his recent retirement.
Because of advances in medication, new devices to improve heart function, and interventional procedures, both surgical and non-invasive, deaths from heart disease have shown a significant decline over the past 10-15 years. While there is a clear decline in mortality, the rate of myocardial infarctions (MI) has not shown this same reduction. The data reflects the fact that because we have improved MI survival, we now have a large population of patients with chronic heart disease, often with late-stage heart failure. Between 60-70% of patients with late-stage heart failure have hearts that were damaged by one or more MIs.
A significant number of patients with late-stage heart failure are now considered for heart transplant. However, due to the scarcity of donor hearts (less than 3,000 for a pool of more than 30,000 eligible patients in the U.S.), mechanical pumps, once considered a rare application, have found their place in the mainstream care of end-stage heart failure patients. LVADs, once solely implanted in patients awaiting heart transplant, have increasingly replaced the need for transplants and are now a long-term option. They have allowed some patients to avoid the complex medication regimens and surgical complications that accompany a heart transplant. These devices may even replace the heart completely in the future, a thought that is fascinating for the future of our profession. The advances in bearing technology, including the replacement of cyclic with continuous flow pumps, the reduction in size and conversion from pneumatic to electric power, have made LVADs a feasible therapy for these patients. The technologic advances have extended pump lifespan from 1-2 years to 4-5 years and allowed patients to return to a full and active life with the device providing a significant portion of the cardiac output to assist the weakened left ventricle.
Engineering research continues in the areas of smaller pumps; induction-charged batteries that can be implanted to eliminate the skin breach for power wires that often leads to infection; and smaller incisions for implantation. There is even early research on VAD implantation using percutaneous techniques. Medical care is advancing to better understand the bleeding complications related to clotting factor changes, prevention of infections and pump settings to optimize function and minimize complications. Fully computerized pump control will eventually adjust the pump to exercise, rest, sleep and other unique demand situations.
As with any other new medical technology, these advances come at a price. With health care costs escalating each year, and cardiology accounting for a significant portion of the Medicare budget, there is much debate about how widespread innovative cardiac devices and procedures, such as LVADs, should be. For patients who return to productive lives with an LVAD, the overall cost may well be reasonable considering the return to productivity and the reduced long-term cost of care for severe heart failure. As more patients who will not receive a heart transplant are provided with destination LVADS, the cost analysis is likely to be favorable for LVAD use. However, they are still likely to generate considerable debate on the ethics of their use in an already overburdened health care system. Given the fact that most of the patients who need an LVAD have hearts damaged by coronary disease, we may see a push to reduce demand by achieving higher levels of prevention.