Heart Transplantation and Mechanical Circulatory Support—From Established Treatment to Current Trends in Management of End-Stage Heart Failure

In patients with end-stage heart failure refractory to medical and cardiac resynchronisation therapy, heart transplantation is recognised as the treatment of choice. As compared to medical therapy, heart transplantation is considered to be associated with a survival benefit, to enhance functional capacity and improve quality of life, provided that patients are properly selected in accordance with guidelines. However, a powerful trial to compare heart transplantation with conventional management is still lacking and is unlikely to be performed. Individually tailored anti-rejection regimens, based on the currently used immunosuppressive agents, have produced an excellent survival rate following heart transplantation. Unlike the increase in survival in the early phase after transplantation, the attrition rate over the long term has remained similar in recent decades, largely because of associated complications such as chronic allograft vasculopathy and malignancy, the incidence of which could not be markedly reduced. Since the number of heart transplantations is limited due to the shortage of donor organs, and since, in parallel, the number of patients with end-stage heart failure is constantly increasing, mechanical circulatory support is gaining in importance. The pulsatile devices originally used were associated with a high frequency of adverse events such as bleeding and thromboembolic events, noisiness and patient discomfort, which prevented widespread application. The introduction of continuous- flow pumps which are silent and comfortable, and cause fewer side effects, has revolutionised mechanical circulatory support. Since survival on such devices has significantly improved as compared to the previous era, implant rates have dramatically increased, particularly as an alternative to transplantation. In carefully selected patients the outcome of destination therapy approaches survival rates close to those after heart transplantation.