The pharmacotherapy implications of ventricular assist device in the patient with end-stage heart failure.

Advances in mechanical circulatory support, such as the use of ventricular assist devices (VADs), have become a means for prolonging survival in end-stage heart failure (HF). VADs decrease the symptoms of HF and improve quality of life by replacing some of the work of a failing heart. They unload the ventricle to provide improved cardiac output and end-organ perfusion, resulting in improvement in cardiorenal syndromes and New York Heart Association functional class rating. VADs are currently used asa bridge to heart transplantation, a bridge to recovery of cardiac function, or as destination therapy. Complications of VAD include bleeding, infections, arrhythmias, multiple organ failure, right ventricular failure, and neurological dysfunction. Patients with VAD have unique pharmacotherapeutic requirements in terms of anticoagulation, appropriate antibiotic selection, and continuation of HF medications. Pharmacists in acute care and community settings are well prepared to care for the patient with VAD. These patients require thorough counseling and follow-up with regard to prevention and treatment of infections, appropriate levels of anticoagulation, and maintenance of fluid balance. A basic understanding of this unique therapy can assist pharmacists in attending to the needs of patients with VAD.

Improved survival after heart transplantation in patients with bridge to transplant in the recent era: a 17-year single-center experience.

BACKGROUND: Ventricular assist device (VAD) implantation as a bridge to transplant (BTT) has become an important approach for heart transplant candidates. In this study we document our institutional long-term results and recent improvements in BTT therapy. METHODS: We retrospectively studied 531 consecutive heart transplant recipients between January 1990 and August 2007. The cohort was divided into old orthotopic heart transplant (OHT) without device (oOHT; n = 399, January 1990 to July 2003), old BTT (oBTT; n = 41, January 1990 to July 2003), new OHT without device (nOHT; n = 58, August 2003 to August 2007) and new BTT (nBTT; n = 33, August 2003 to August 2007) groups. Demographics and post-transplant outcomes were assessed. RESULTS: Post-transplant survival in the nBTT group improved significantly compared with the oBTT group (log-rank test, p = 0.01) and survival in the nOHT group tended to be higher than in the oOHT group (p = 0.19). Survival in the oBTT group was significantly worse than in the oOHT group (p < 0.01). However, there was no difference between the nBTT and nOHT groups. The mean period of BTT support was 113 (range 5 to 524) days in the oBTT group and 148 (range 38 to 503) days in the nBTT group. Multivariate analysis revealed diabetes (p < 0.01) and biventricular support (p = 0.04) as significant independent predictors of post-transplant mortality. CONCLUSIONS: Post-transplant survival has improved in recent BTT patients. Indeed, recent outcome for OHT after BTT has become equivalent to that for OHT without VAD. These data suggest that advances in device technology and our institutional multidisciplinary program have improved survival and allow BTT candidates to have an outcome equivalent to that of non-VAD patients in the recent era.