Mechanical Support in Heart Failure: Continuous Flow Devices

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The MD Magazine Peer Exchange “Advances in Heart Failure Management” features expert opinion and analysis from leading physician specialists on the latest developments in heart failure research, diagnosis, and management.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Michael Felker, MD, MHS, Professor of Medicine, Chief of the Heart Failure Section, Director of the Heart Center Clinical Research Unit, and Director of the Advanced Heart Failure Fellowship at Duke University School of Medicine
• Jim Januzzi, MD, Roman W. DeSanctis Endowed Distinguished Clinical Scholar in Medicine at Massachusetts General Hospital and Hutter Professor of Medicine at Harvard Medical School
• Christian Schulze, MD, PhD, Associate Professor of Medicine, Division of Cardiology at Columbia University Medical Center, and Director of Research for the Center of Advanced Cardiac Care at Columbia University Medical Center

In this segment of the Peer Exchange, the panelists discuss the current status of mechanical support in treating patients with heart failure. Along with new pharmacologic options for acute and chronic heart failure, there have also been many advances made using other strategies, such as gene therapy, stem cells, new monitoring devices, and mechanical support.

In terms of mechanical support, it may be the case that the more primitive pulsatile devices are better associated with cardiac remodeling, says Salgo, than the newer continuous flow devices, but Schulze says it is difficult to know if one device is superior to the other because head-to-head comparisons have not been conducted and never will be “because the first generation of devices has basically retired now.” Without having a head-to-head trial, we still do know that “the absence of the pulse” seen with continuous flow devices “might not necessarily be a good thing,” says Schulze. While it is unknown whether this absence causes poor outcomes, he says, “it feels like this is a physiologic response that we need.”

On the other hand, Schulze adds that devices for mechanical support in general, and the continuous flow devices in particular, “are associated with a tremendous decrease in mortality.” He says that one-year mortality is less than 20 percent for these devices, which is a large improvement. At baseline, these patients “have a mortality and survival of less than 50 percent per year, and now suddenly those patients have a survival of more than 80 percent per year. So that’s a tremendous gain.”

The technology is improving incrementally, says Felker, who points out that “developers are really trying to engineer intermittent pulsatility even into the non-pulsatile devices as a way of potentially counteracting” issues such as gastrointestinal bleeding in patients with a left ventricular assist device.