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Ann Thorac Surg 1995;60:290-291
© 1995 The Society of Thoracic Surgeons
DR O. H. FRAZIER (Houston, TX): Thank you, Dr Mehta, for the opportunity to review this excellent report.
Originally, the LVAD was developed to save patients facing imminent death. Over the last few years, however, studies have demonstrated that LVADs also decrease the cost of care and increase the posttransplantation survival rate of these critically ill patients. Our experience thus far has convinced us of the need and the possibility of developing a permanently implantable device.
Recently, we at the Texas Heart Institute were granted a protocol for release of patients awaiting transplantation on the LVAD. Since the fall of 1991, 3 patients have been allowed 225 day trips, half of which were taken by 2 of the patients. The third patient actually was discharged from the hospital for 6 months, during which time he was able to take a vacation with his wife. We calculated his total cost while waiting for a transplant to be only $27 a day.
As Dr Mehta mentioned, the waiting period for transplantation is increasing. According to the most recent United Network for Organ Sharing data, status I patients waited a mean of 63 days in the intensive care unit before transplantation. The LVADs available today can take these patients out of the intensive care unit, decreasing costs and improving their physical and emotional well-being.
I have two questions for Dr Mehta. First, although you mentioned cost versus charges, I am not sure that the ``real costs'' you spoke of were truly real costs. Would you comment on this? Second, your average waiting time before implantation was 52 days. Has your experience caused you to reassess the time and criteria for implantation?
DR BARTLEY P. GRIFFITH (Pittsburgh, PA): Doctor Mehta, thank you for discussing what those of us involved in mechanical circulatory support have suspected, ie, that these mechanical devices, be it the Pierce-Donachy, the TCI device that Dr Frazier has extensive experience with, or the device that we have had experience with, the Novacor-Baxter device, are quite capable now of providing quality and length of extended support.
I would suggest that because you have shown a parallel cost for inpatient location, that as mechanically supported patients are discharged from Penn State to home, as is done selectively in Pittsburgh, you will show a dramatic decrease in the costs of this therapy relative to medical therapy. It is amazing how little care these patients require and how inexpensive it is to take care of them once the initial investment of the device is made. And I do believe that your comment relative to the earlier use of these devices will be the one that holds the field.
DR EDWARD A. LEFRAK (Annandale, VA): We have performed transplantation in 103 patients over the last 8 years at Fairfax Hospital, and 14 of them have been supported with the TCI LVAD. Our overall actuarial survival rate at 1 year is 93%, and all 14 of the TCI-supported patients survived and are still alive for 100% survival up to 6 years.
My question really relates to the other side of the coin, that is, the medical therapy. I noticed that you showed a woman in the intensive care unit and mentioned a cost of $3,300/day for medical treatment. We have cared for nearly all our LVAD patients and the vast majority of pharmacologically supported patients on our regular floor telemetry unit. It is the same unit to which patients are admitted and cared for after heart operations. These patients certainly need to be in the hospital and require inotropic or balloon pump support, but they do not need to be in an intensive care unit. Patients on dopamine, amrinone, or the LVAD are supported and managed on the telemetry unit safely and comfortably at a much reduced cost of that associated with the intensive care unit. My question is whether or not you have tried this approach to reduce overall costs and enhance patient comfort during the pre--heart transplantation phase.
DR MEHMET C. OZ (New York, NY): Recently we also compared the cost of heart transplantation versus LVAD and specifically looked at quality of life in conjunction with cost. I notice in your experience you had 92% survival until discharge in the LVAD group and 56% in the medical management group. So in addition to the fact that you can look at costs per day in the hospital and find equivalency, if you calculate out costs per quality life year saved, I think the difference would be even more significant. We found this to be true. We evaluated our first 40 long-term support devices and found them to be fairly comparable with heart transplantation with regard to both survival and cost.
DR MEHTA: I thank all the discussants for their generous comments. Doctor Frazier, regarding the questions of costs and charges, the analysis was chosen in this way so that we could see whether or not there were in fact hidden costs. It was interesting that there was no statistical difference between the evaluations of costs per day and charges per day.
Regarding the issue of timing of implantation, our experience over the last 4 years has demonstrated an inclination to put these devices in earlier with the hope of supporting these patients and getting them back on the road to rehabilitation earlier.
Doctor Lefrak, in answer to the question of intensive care unit versus floor status of these patients, both our group of medically managed patients and those with LVADs at this time are treated in an intensive care step-down unit. The patients undergoing chronic inotropic support have not been transferred to the floor in fear of violating United Network for Organ Sharing criteria and thus sacrificing the status I classification of these patients. Current United Network for Organ Sharing criteria for status I patients dictate those patients receiving inotropic support must be cared for in an intensive care unit setting to retain their status.
Related Article
Ann. Thorac. Surg. 1995 60: 284-290.
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