To the Editor: The study of long-term outcomes and costs of ventricular assist devices by Dr Hernandez and colleagues1 provided some interesting data, but because of the large amount of progress in this field over the past 2 years, it is of mostly historical value for comparisons with current outcomes with these devices. Also, the observations are too broad because of the inclusion of patients with multiple device indications, various devices used for diverse indications, and unknown indications for readmissions.
Mechanical circulatory support is moving rapidly away from pulsatile design pumps (the exclusive type reported by Hernandez et al) to a new generation of nonpulsatile, continuous flow design.2 In one study, using the new design as a bridge to a transplantation resulted in 68% 1-year actuarial survival; at 3 months there was a 73% increase in patient-assessed quality of life by Kansas City Cardiomyopathy Questionnaire at 3 months (from 33 to 57) and a significant improvement in functional capacity.2 In addition, the major adverse effects were significantly less than reported with the older pulsatile design pumps2 - 3 used in the study by Hernandez et al.
The most important conclusion from the study by Hernandez et al is that patient selection is the key to improved outcomes. A risk stratification score may allow preoperative identification of patients with an extremely high risk of not surviving to hospital discharge following ventricular assist device implant as an alternative to transplantation.4 In addition, it appears that centers offering ventricular assist device therapy may need to do a minimum number of implantations annually to be able to provide good outcomes; the median number of implantations per hospital was only 1 per year.
Regarding costs, a study of 44 patients receiving medical therapy alone for advanced heart failure found a mean cost of nearly $80 000 during the last 6 months of life,5 more expensive than for other terminal conditions. Quality of life and functional improvement must also be factored into assessment of the benefit of new therapies.
Financial Disclosures: Dr Miller reported receiving research support, honoraria, and consulting support from Thoratec and serving on the advisory board for Heartware.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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