Ann Thorac Surg 2001;72:1305
© 2001 The Society of Thoracic Surgeons
Invited commentary
James D. Fonger, MDa
a Lenox Hill Hospital, 130 E 77th St, 4th Floor, New York, NY 10021, USA
e-mail: jfonger{at}heartnet.org
Heart transplantation came into its own over 20 years ago and is now an established therapy for end-stage heart failure. However for the reasons cited in this manuscript some have said you effectively "trade one chronic disease for another after transplantation" given the maintenance requirements these patients must live with to care for their new heart. The preoperative waiting, procurement costs, and subsequent medication expenses make this significantly more expensive than the reparative strategies outlined in this manuscript for treating the failing ventricle.
Twenty years ago these advanced reparative strategies were not options for the heart failure patient. Coronary bypass was felt to be too risky in the face of severely compromised ventricular function. The techniques for mitral valve repair were just developing and had not been applied extensively for the chronically dilated left ventricle. The notion of surgically reducing ventricular volume to improve systolic function in nonaneurysmal hearts had not even been considered. Twenty years later these are all now viable alternatives for the heart failure patient and considering a reparative option becomes an important question to ask.
Comparing different patient treatments and their actual costs is fraught with challenges. The author have come as close as is practical in drawing comparisons between subsets of patients actually treated in the real world. Their conclusion is convincing despite these limitations and begs the question of why procurement and medications need to be as expensive as they presently are. Longer hospitalizations will be a fact of life in a group of patients in which you elect to wait around for the random event of donor availability. Reparative strategies win on all these fronts and the cost savings inevitably follow. The risk to patients of occasionally failing to improve their heart function with a reparative procedure can now be ameliorated by better temporary ventricular assist devices available as safety nets and bridges to later transplantation.
The findings of the authors are important information for planning heart failure treatment today and will be even more important tomorrow. The advent later this year of the first human use of a new prosthetic total heart along with a new generation of axial flow implantable ventricular assist devices will further alter this equation. This message is good news for patients currently sitting on transplant waiting lists and for the health care system that is supporting this approach. Transplant centers may need to reevaluate the candidates currently on their waiting lists and possible relegate heart transplantation more towards those that either don’t qualify for or fail to benefit from a reparative cardiac procedure.
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A cost comparison of heart transplantation versus alternative operations for cardiomyopathy
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Ann. Thorac. Surg. 2001 72: 1298-1305.
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