The financial burden of destination left ventricular assist device therapy: who and when?

Heart failure continues to be an economic health care burden of profound proportion. The disease in its end stage has limited therapeutic options. Transplantation is limited by the number of available organs. Mechanical assist therapy has continued to be an increasingly feasible strategy for bridging patients to heart transplantation but is also now used in place of transplantation. The REMATCH trial was the first trial to document the failure of medical therapy in end-stage heart failure when compared with mechanical support. However, one of the primary concerns is the marked expense involved with this invasive therapy. As the cost of ventricular assist devices (VADs) for destination therapy has been appraised in the medical literature, and through examination of patients who have been implanted in the "post-REMATCH era," a subset of patients has emerged in whom VAD implantation is futile, as well as another subset that clearly benefits both in quality of life as well as in mortality. We review the current literature on VAD feasibility for destination therapy as well as ongoing trends in careful patient selection to improve outcomes and, implicitly, cost benefit of VAD therapy.