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Of Governators & Nihilists: Musings on My First Symposium of the 2014 ISHLT Meeting

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Scott Feitell, DO
Drexel College of Medicine
Philadelphia, PA, USA

Pre-Meeting Symposium 12: To VAD or to Transplant ... that is the question. Sadly my ability to quote Shakespeare does not go much further, and my boxed lunch is waiting, so we will have to delve straight into our pre-meeting Symposium straight away as we have much to review.

You can always tell when an Austrian is lecturing you, because you know you will see at least three references to Arnold Schwarzenegger in his talk, and Dr. Andreas Zuckermann did not disappoint. Throwing the opening volley in this outstanding "debate," Dr. Zuckermann reviewed all the latest in graft survival. Showing his age, he did reference the "good old days" when his first presentation at ISHLT was probably quite literally "a slideshow," he reminded us all of the wonders and potential transplant were thought to and ultimately did provide. But like so much of the modern era, technique, technology and experience has further enhanced our ability to provide transplant to thousands of patients, but there is still room for improvement. Hailing his motherland, his "Mother Plan" of Vienna has further managed to improve both shortterm complications and perhaps improve long term survival, by enhancing graft procurement procedures, improving communication with his team of ICU docs and anesthesiologists and surgeons, and improving the training of his surgeons. As Dr. Zuckermann points out though, many challenges remain for further improvements to occur, including aggressive treatment of vasculopathy, improved screening and treatment of malignancies, protecting the kidneys and ultimately Mother Nature herself as our patients become octogenarians and older. Most importantly he emphasized the need to individualize immunosuppression to our individual patients, noting a "one-size-fits-all" approach is no longer acceptable.

All compelling arguments, but then Dr. Frank Pagani took the stage and offered his assessment of Mechanical Circulatory Support. Sadly, he did not reference the "Governator" once, so he may have lost the argument before he even started, but he did offer some interesting insight into defining survival and what it means to the post-LVAD patient. Clearly, survival means much more than breathing, and we must be careful to incorporate quality into any metric that includes quantity. He was quick to point out that, like so much of medicine, MCS requires tradeoffs, and though six-minute walk tests might improve and survey scores on quality of life may increase, things like stroke and GI bleed clearly limit "surviving." Though as our use of these newer continuous flow devices increases, so does our learning curve, and suddenly things like screening for co-morbidities and assessing the right heart a little more carefully might further improve survival. In Dr. Pagani's opinion, it seems we are at a crossroads with MCS, and as further developments in medical management come through the pipeline it will be important to compare outcomes and patient quality of life directly to the benefits and risks of LVAD therapy.

Now, I don't know about you, but neither of these guys really sealed the deal for me, (luckily for me I've already secured a heart failure fellowship for next year so I can be a little more cavalier and unbiased in assessing this debate), so let's see who wins round 3.

Luckily our next presenter, Dr. Kathleen Grady reviewed some great data and metrics on how we can actually assess quality of life in our VAD and transplant patients. It became abundantly clear listening to her speak, that actually both sets of patients fair pretty well. The rate-limiting step it seems in settling this debate is that long-term data from our MCS patients is just lacking at this point, as it remains the newer technology. Promising though, is that, at one year, it seems both groups of patients give favorable scores in several measures of quality of life. It is interesting she points out that certain differences remain as pertains to disability and depression when we account for our younger patients and our female patients, but overall things do look favorable. Clearly, as Dr. Grady points out, longer-term survival data, and better head-to-head studies will help us settle this debate in the near future.

But what about our patients that can't get a VAD, or don't qualify for a transplant? Or even worse, what if they are one of the patients that get a devastating complication that is not reversible? Dr. Jane Maclver offered a great deal of insight in her talk on Palliative Care in the heart failure setting. Quite poignantly she noted that palliative care is not a "consult team" or a discipline, but a philosophy that we all must adopt to better serve our patients. She offered some very interesting data that showed adopting this philosophy early and often with all our patient interactions can not only make decision making easier for our patients, but help alleviate pain and provide symptom relief throughout the entire course of care we provide our patient.

Now at this point I had lost track of who was winning, the "VAD-ers" or the "transplanters," and I was really thinking of getting another cup of coffee, but then Dr. David Taylor took the stage. Not only is this guy a former president of the ISHLT, but he also offered me my recently acquired Heart Failure Fellowship, so I felt obligated to stick around and hear what he had to say. Now I didn't really picture this guy as a Nihilist, but with a few more quotes from Nietzche and I would have had to rethink signing my offer letter (or at least brush up on the Apollonian and Dionysian). It also became abundantly clear that I better go on a diet. Heaven forbid I find myself standing on a bridge in Cleveland one day, he may end up pushing me over the edge to save a transplant patient. What does this have to do with heart failure, honestly, I'm not sure. He pontificated on autonomy and beneficence, and non-maleficence and justice and all those other Medical Ethics 101 terms. I had forgotten about since I last needed to renew my IRB "good standings" only to realize what his whole point was. His talk was titled "Patient Selection or Patient Preference" and I think his point was...oh man, I honestly got so caught up in his example of pushing a fat guy over a bridge to stop a train that was about to run into a crowd of people that I missed his actual point (you really had to be there). In all seriousness, it became abundantly clear from his talk that the ethical and philosophical decisions we as physicians make can be just as important and complex as the medical ones, and naturally there are no easy answers.

Wrapping up the session, Dr. James Kirklin, another former president of the ISHLT (I guess I'm not getting my coffee) took to the stage and wrapped up this debate. He made it abundantly clear that risk stratifying our patients better and accounting for co-morbidities and assessing quality of life objectively are all keys to making such difficult decisions. New scoring metrics will need to be developed that can weigh these factors effectively will help us, and our patients better decide what option will work for them.

Luckily this is not an op-ed piece, so I don't have to pick a winner. It is clear though that despite all the advancements in technology there are significant drawbacks to both transplant and mechanical circulatory support. As Arnold would say, "I'll be back" with an answer maybe after a few more years and a few more debates.

Disclosure Statement: the author has no conflicts of interest to report.

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