Outcomes With Current Devices Are We Really Improving?

Dip. CardiovascolareDirettore Ettore Vitali

Outcomes With Current Devices

Are We Really Improving?


Intention to Treat n % of 655

Bridge to transplant 513 78.3%

Bridge to recovery 35 5.3%

Destination Therapy 78 11.9%

Not specified 29 4.4%

Total 655 100%

ISHLT/MCSD Analysis, n=655

ISHLT 2005

J Heart Lung Transplant 2005;24:1182-1187


Device Strategy at Implant %

Bridge to Recovery 27 5 %

Bridge to Transplant 460 80 %

Destination Therapy 90 15 %

INTERMACS: March 2006 – March 2008, n = 483

Total 483 100 %



Quality of Live


ISHLT/MCSD Analysis

0

50

100

150

200

250

300

0 1 2 3 4 5 6 7 8 9 10 11 12

Cu

mu

lati

ve E

ven

ts p

er

100

Pa

tie

nts

Months after Device Implant

Bleeding Episodes (n=396)

Infection Episodes (n=668)

Thromboembolism Episodes (n=86)

75

175

18


INTERMACS first DATABASEBUT:

• No standardized INDICATIONS

• NO consensus between different CENTERS

• Different VADs


Personal experience with INCOR(14 pts)

5 transplanted

9 non trasplanted

4 died 1 perioperative

5 months

14 months

35 months

4 on going

1 recovery


Personal experience with INCOR

• Less neurological problems

(more aggressive anticoagulation protocol)

• High infective risk

• Good Quality of Live


Devices Cultural

Indications

IMPROVING




SHORT-TERM LONG-TERM

• Bridge to RecoveryBridge to Recovery

• Bridge to BridgeBridge to Bridge

• Bridge to TxCBridge to TxC

• Destination TherapyDestination Therapy

INDICATIONS


VAD as DIALYSIS


VAD as CRT


CULTURAL IMPROOVEMENT


Patients

Is it only a prosthesis?


256

16

10

26

VAD CANDIDATES

MedicalMedical

therapytherapy

3.5%3.5%

282 CHF pts282 CHF pts

txtx

No TxNo Tx


VAD CANDIDATES in ITALY

164 169 164 164418661

43183

129309

0

20000

40000

60000

80000

100000

120000

140000

< 1 1 - 14 15 - 24 25 - 44 45 - 64 65 - 74 >= 75

63985 pts x 63985 pts x

3.5% =3.5% = 2239 pts2239 pts


Health providersDevices

Batteries

Hospital

Ambulatory

Follow up and manteinance

VADs had to be paid for 3-5 years

Who pays?


today

And tomorrow?


The Value of Medical Spendingin the United States, 1960 –2000

N Engl J Med 2006;355:920-7.

Causes of Increases in Life Expectancy among Newborns, 1960–2000.

Cause Increase in Life Relative

Expectancy Contribution

yr %

Reduction in rate of death from cardiovascular disease 4.88 70Reduction in rate of death in infancy 1.35 19Reduction in rate of death from external causes 0.36 5Reduction in rate of death from pneumonia or influenza 0.28 4Reduction in rate of death from cancer 0.19 3

Total 6.97 100

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Outcomes With Current Devices Are We Really Improving?