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proI am a cardiologist practicing at an institution experienced in heart transplantation. We recently started a VAD program which we are really excited about. Given this bias, I believe that VAD implants should be handled by transplant centers and not by standard cardiothoracic surgery centers. Indeed, transplant is still the first option for advanced heart failure. Although the most foreseeable scenario may be that VAD therapy will be for patients with failing hearts as what dialysis is for patients with failed kidneys. VADs are implanted either to bridge a patient until an organ is available, or to restore as a surrogate survival option for those with absolute contraindications for transplant. These indications can be appropriately managed only by a transplant center, or by a center strictly connected with a transplant center. Thus, in the context of a public healthcare system, health authorities should regulate VAD implants by allowing only selected centers with periodic auditing of indications and outcomes similar to transplant.

The compelling issues of costs, possible restrictions, and over/under treatment, are very difficult to regulate and the decision-making system should be responsibly driven by physicians and surgeons. I think that a very effective tool is to institute a registry similar to INTERMACS in the US. Healthcare authorities, inspired by scientific societies, may then provide national guidelines, tailored by the local system, to identify indications and age limits, to be periodically revised based on meaningful data from the registries. It is only by revising expected outcomes that it would be possible to regulate implants effectively, avoiding dangerous liberalization. Of course, to support these concepts in a rational manner, national healthcare systems need money-not cuts-like we are now facing in southern Europe, thus forecasting a downgrade of our expectation for cutting-edge therapies. In my country, for instance, 70% of the national budget for transplants and organ procurement activities was cut by the Health ministry, leaving the costs mostly on the shoulders of the local governments. In this scenario, it is quite unlikely that money will be allocated for the burgeoning VAD programs. This will induce transplant centers towards a policy of "responsible restriction" thereby limiting the bridge to transplant indication to very selected patients. The efforts of the ISHLT in supporting an international registry and developing MCS guidelines, will be indispensable and akin to helping the performer "teeter-totter on a tight rope with a glass of battery acid on his forehead".

Dr Seymour Moni


Anyone interested in battling the CON side? If so, please submit your opinion to Susie Newton ( no later than Wed, July 25th, for publication in the August 2012 Links issue.