From the Guidelines
Patients with end-stage organ failure who are not candidates for traditional transplantation should be considered for Left Ventricular Assist Devices (LVADs) as a bridge to transplantation or destination therapy, as evidenced by the 2016 ESC guidelines 1. For heart failure, LVADs provide mechanical circulatory support by pumping blood from the left ventricle to the aorta, with actuarial survival rates of 80% at 1 year and 70% at 2 years in predominantly non-transplant-eligible patients 1. The INTERMACS registry shows better outcomes in patients implanted with a higher INTERMACS class, although the majority of VAD implants are done at INTERMACS levels 1 – 3 1.
Key Considerations for LVAD Implantation
- Evaluation of RV function is crucial since postoperative RV failure greatly increases perioperative mortality and reduces survival to, and after, transplantation 1.
- Patients with chronic biventricular failure or a high risk for persisting RV failure after LVAD implantation may require implantation of a biventricular assist device (BiVAD) 1.
- The implantation of a total artificial heart with removal of the native heart should be restricted to selected patients who cannot be treated with an LVAD 1.
Management and Complications of LVADs
- Patients require anticoagulation therapy and antiplatelet therapy to prevent device thrombosis and bleeding 1.
- Complications include device thrombosis, infection, and bleeding, which can be managed with appropriate medical and surgical interventions 1.
Alternative Options for End-Stage Organ Failure
- For kidney failure, Continuous Renal Replacement Therapy (CRRT) offers ongoing filtration through modalities like continuous venovenous hemofiltration (CVVH) or hemodiafiltration (CVVHDF) 1.
- Other options include implantable artificial kidneys under development and peritoneal dialysis for ambulatory patients 1.
From the Research
Artificial Organs for End-Stage Organ Failure
- Artificial organs, such as Left Ventricular Assist Devices (LVADs) for heart failure and Continuous Renal Replacement Therapy (CRRT) for kidney failure, offer alternative treatment options for patients with end-stage organ failure when traditional transplantation is not possible 2, 3.
- LVADs can improve survival in patients with advanced heart failure, but their use in patients with kidney disease is complex and requires careful consideration 2.
- For patients with both heart and kidney failure, simultaneous heart and kidney transplantation (HKT) after VAD implantation is a viable treatment option, with excellent outcomes reported in some studies 4.
Treatment Options for Patients with End-Stage Organ Failure
- LVADs can be used as a bridge to heart transplantation or as destination therapy for patients with advanced heart failure 2, 3.
- CRRT, including hemodialysis and peritoneal dialysis, can be used to support patients with kidney failure, including those with LVADs 2, 3.
- Artificial organs can be used to bridge the time to transplantation, but transplantation remains the first choice for many chronic diseases 5.
- Bioengineering techniques, such as decellularization-recellularization, are being explored to develop artificial organs for transplantation, with promising results in various organs, including the heart, lung, liver, pancreas, intestine, and kidney 6.
Challenges and Considerations
- The use of artificial organs in patients with end-stage organ failure is complex and requires careful consideration of various factors, including blood pressure management, anemia management, and hemodialysis protocols 2, 3.
- The development of artificial organs for transplantation is limited by the availability of suitable scaffolds and the need for optimization of organ-specific recellularization techniques 6.
- Xenotransplantation is currently an experimental alternative solution, and artificial organs are being used to increase and improve the survival of patients waiting for transplantation 5.