| Keywords [eng] |
Advanced heart failure, durable mechanical circulatory support, left ventricular assist device, HeartMate 3, orthotopic heart transplantation, survival outcomes, complications, quality of life, functional outcomes, healthcare utilization, patient selection, bridge-to-transplant, destination therapy. |
| Abstract [eng] |
Heart failure is a major and increasing global health burden, and a clinically important subgroup of patients progresses to advanced heart failure despite guideline-directed medical therapy. At this stage, conventional treatment is often insufficient, and advanced therapies such as durable mechanical circulatory support, particularly left ventricular assist devices, and orthotopic heart transplantation must be considered. Heart transplantation has traditionally been regarded as the gold-standard treatment for eligible patients, but its use is limited by donor scarcity, strict candidacy criteria, and long-term complications related to immunosuppression. In parallel, left ventricular assist device therapy has evolved into an established treatment option, especially with contemporary third-generation devices such as the HeartMate 3. The aim of this thesis was to critically evaluate contemporary evidence comparing durable mechanical circulatory support and orthotopic heart transplantation in adults with advanced heart failure. The objectives were to compare survival, complication profiles, quality of life, functional outcomes, healthcare utilization, costs, and the influence of patient selection and treatment timing. This thesis was conducted as a structured literature review using contemporary adult studies identified through PubMed and Embase. Due to heterogeneity in study design, patient populations, device generations, outcome definitions, and follow-up duration, the evidence was synthesized qualitatively rather than by meta-analysis. The reviewed evidence shows that survival after left ventricular assist device implantation has improved substantially across device generations. Contemporary HeartMate 3 therapy has narrowed the early and intermediate-term survival gap with heart transplantation, particularly compared with older devices. However, heart transplantation retains the strongest long-term survival evidence. Survival comparisons are highly dependent on follow-up duration, device generation, treatment indication, and patient selection. Transplant recipients are highly selected, whereas left ventricular assist device cohorts are more heterogeneous and include bridge-to-transplant, bridge-to-candidacy, and destination-therapy patients. The complication profiles of the two therapies differ substantially. Left ventricular assist device morbidity is mainly driven by gastrointestinal bleeding, stroke, infection, right heart failure, arrhythmias, aortic regurgitation, and device malfunction. Although HeartMate 3 has reduced pump thrombosis and stroke compared with earlier devices, gastrointestinal bleeding, driveline infection, and right heart failure remain important. Heart transplantation complications are mainly related to primary graft dysfunction, rejection, cardiac allograft vasculopathy, immunosuppression, infection, malignancy, and renal dysfunction. Both therapies improve quality of life and functional status, but with different long-term burdens. Healthcare utilization is substantial for both therapies, especially early after intervention, and urgent left ventricular assist device implantation is generally more resource-intensive than elective implantation or primary transplantation. Overall, durable mechanical circulatory support and heart transplantation should be viewed as complementary rather than strictly competing therapies. Heart transplantation remains preferred for eligible patients, while contemporary HeartMate 3 therapy offers an effective alternative for patients awaiting, temporarily ineligible for, or unsuitable for transplantation. |
