Outcomes With Current Devices
Are We Really Improving?
Dip. Cardiovascolare
Direttore Ettore Vitali
ISHLT/MCSD Analysis, n=655
Intention to Treat
n
Bridge to transplant
Bridge to recovery
Destination Therapy
Not specified
513
35
78
29
78.3%
5.3%
11.9%
4.4%
Total
655
100%
ISHLT
2005
J Heart Lung Transplant 2005;24:1182-1187
Dip. Cardiovascolare
Direttore Ettore Vitali
% of 655
INTERMACS: March 2006 – March 2008, n = 483
Device Strategy at Implant
%
Bridge to Recovery
27
5%
Bridge to Transplant
460
80 %
Destination Therapy
90
15 %
Total
483
Dip. Cardiovascolare
Direttore Ettore Vitali
100 %
Dip. Cardiovascolare
Direttore Ettore Vitali
Quality of Live
Dip. Cardiovascolare
Direttore Ettore Vitali
Cumulative Events per 100 Patients
ISHLT/MCSD Analysis
300
250
200
Infection Episodes
(n=668)
150
175
100
75
Bleeding Episodes
(n=396)
18
Thromboembolism
Episodes (n=86)
50
0
0
1
2
3
4
5
6
7
8
9
Months after Device Implant
Dip. Cardiovascolare
Direttore Ettore Vitali
10
11
12
INTERMACS first DATABASE
BUT:
• No standardized INDICATIONS
• NO consensus between different
CENTERS
• Different VADs
Dip. Cardiovascolare
Direttore Ettore Vitali
Personal experience with INCOR
(14 pts)
5 transplanted
4 died
1 perioperative
5 months
14 months
35 months
9 non trasplanted
4 on going
1 recovery
Dip. Cardiovascolare
Direttore Ettore Vitali
Personal experience with INCOR
• Less neurological problems
(more aggressive anticoagulation protocol)
• High infective risk
• Good Quality of Live
Dip. Cardiovascolare
Direttore Ettore Vitali
Indications
Cultural
Devices
IMPROVING
Dip. Cardiovascolare
Direttore Ettore Vitali
Dip. Cardiovascolare
Direttore Ettore Vitali
Dip. Cardiovascolare
Direttore Ettore Vitali
INDICATIONS
SHORT-TERM
LONG-TERM
• Bridge to Recovery
• Bridge to TxC
• Bridge to Bridge
• Destination Therapy
Dip. Cardiovascolare
Direttore Ettore Vitali
VAD as DIALYSIS
Dip. Cardiovascolare
Direttore Ettore Vitali
VAD as CRT
Dip. Cardiovascolare
Direttore Ettore Vitali
CULTURAL
IMPROOVEMENT
Dip. Cardiovascolare
Direttore Ettore Vitali
Patients
Is it only a prosthesis?
Dip. Cardiovascolare
Direttore Ettore Vitali
VAD CANDIDATES
282 CHF pts
256
tx
16
No Tx
10
26
Medical
therapy
3.5%
Dip. Cardiovascolare
Direttore Ettore Vitali
VAD CANDIDATES in ITALY
129309
140000
120000
63985 pts x
3.5% =
100000
80000
2239 pts
60000
43183
40000
18661
20000
164
169
164
1644
0
<1
1 - 14
15 - 24 25 - 44 45 - 64 65 - 74
Dip. Cardiovascolare
Direttore Ettore Vitali
>= 75
Health providers
Devices
Batteries
VADs had to
be paid for 3-5
years
Hospital
Ambulatory
Follow up and
manteinance
Dip. Cardiovascolare
Direttore Ettore Vitali
Who pays?
today
And tomorrow?
Dip. Cardiovascolare
Direttore Ettore Vitali
The Value of Medical Spending
in 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
Expectancy
Relative
Contribution
yr
%
Reduction in rate of death from cardiovascular disease
Reduction in rate of death in infancy
Reduction in rate of death from external causes
Reduction in rate of death from pneumonia or influenza
Reduction in rate of death from cancer
4.88
1.35
0.36
0.28
0.19
70
19
5
4
3
Total
6.97
100
Dip. Cardiovascolare
Direttore Ettore Vitali