Heart pumps are mechanical devices that can keep people with advanced heart failure alive while they wait for a heart transplant.
The devices are getting better. The left ventricular assist device, or LVAD system, may one day be smaller and completely implantable, making it a game changer, experts say, for advanced heart failure treatment.
The total artificial heart, a different device, is also getting streamlined. A version available now allows patients to go home while they wait for a heart transplant.
We talked to patients with both types and to doctors about the future of heart pump technology.
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Qiana Scott, 34, is used to people staring, wondering about the contraption strapped over her shoulders like a parachute harness with pockets down the side.
"I'm the type of person, don't stare. Just ask me what it is because I will tell you from the beginning to the end," Scott said. "I'll tell you the whole story. They just look. Sometimes I will say, 'It's a heart pump.' "
Her LVAD is a machine that does the work of her heart's left ventricle, the main pumping chamber.
As young as she is, Scott suffered a heart attack in September 2006. She had a second one in July 2009. She was treated with stents and a defibrillator, an implant that delivers a shock to stabilize erratic heart rhythms. But last March, Scott said she started feeling bad again, with shortness of breath, nausea and fluid retention.
Her heart's ejection fraction, a measure of how strongly it was pumping, was about 10 percent, she said. Normally, it is 55 percent to 65 percent.
"I got the LVAD on my 34th birthday, which was October 25," said Scott, who worked as a special transportation van driver before going on disability.
"Before, I would just go to work, come home and go to sleep. I was always tired. I didn't have energy to do anything. On my days off I would sleep all day. Now I go and do whatever I want to do. "Sometimes I forget I have the LVAD," Scott said.
Use of LVAD therapy is increasing.
"We are now supporting about 15 patients on LVAD, some of whom are on the transplant list," said physician Gary Zeevi, medical director of the Bon Secours Advanced Heart Failure Center.
"A couple of our patients who are on the transplant list have chosen not to be actively pursued for transplant," Zeevi said. "They are on the list technically, but they are living their life normally with their (LVAD). They have returned to absolute normal functioning so they don't feel the necessity to have another surgery, to take on the concern of immune-suppression drugs. They don't see any particular need right now but have that option down the road if they choose to do it, or if they need to do it, or if there is an issue with the pump and if they want to transition over to transplant," Zeevi said.
Scott is being evaluated for a transplant. If approved, she will join a list of more than 3,126 others in the United States waiting for heart transplants.
Because there aren't enough donor hearts, the wait can extend to months or longer. The sickest patients get priority. In 2011, a total of 1,994 patients received heart transplants in the United States, and 301 died while on the waiting list, according to data from the Organ Procurement and Transplantation Network.
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Tony Williams, 42, is near the top of the list for a donor heart. He was diagnosed six years ago.
His disease was manageable at first, but he said in "the last year, things went downhill." Williams, who lives in Henrico County, is a veteran and father of three. Heart disease runs in his family, he said, naming his father, brother and a late uncle as also affected.
In July, Williams had a total artificial heart implanted at VCU Medical Center's Pauley Heart Center.
The total artificial heart does the work for left and right ventricles. Even though the LVAD has been approved by the Food and Drug Administration for long-term use in patients not eligible for transplant, the artificial heart is approved for temporary therapy for patients waiting for transplants.
"For Tony and other people like Tony, there are many reasons that we use the artificial heart," said cardiologist Keyur B. Shah, medical director of the mechanical circulatory support program at VCU Medical Center.
"It's typically preferable to put an LVAD in. But the artificial heart is reserved for certain scenarios," Shah said. "In Tony's scenario, his right ventricle was extremely poor. The risk for right ventricular failure in him was much higher than in patients we consider for an LVAD."
With the artificial heart, Williams said he felt better almost immediately. Getting used to the device was an adjustment, but overall, eight months out, he considers it low-maintenance.
Traditionally, artificial-heart patients stay in the hospital while waiting for a transplant because the console that controls the heart is desk-sized.
Williams is among a small group of patients who are part of a clinical study testing a portable console called the Freedom Driver, which can be carried in a backpack. The device weighs 13.5 pounds.
"This gives you freedom to get out and live a normal life. I go shopping. I do most of the cooking at home. I do cardiac rehab three times a week," Williams said. "It means the world to me. It gives you extra time. A lot of people don't know about these machines. They don't know the options are out there."
Shah said VCU has done 61 total artificial-heart implants. Of that number, 90 percent either have been transplanted or are still using the device.
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Patient criteria for the heart is specific: both ventricles must be failing, other treatments aren't working and the patient is in imminent danger of death and waiting for a donor heart.
Who should get an LVAD is less clear. Even with the increased use in recent years, some experts think anywhere from 40,000 to 200,000 people with heart failure could benefit from LVAD therapy.
"There is one group that says we should put them in … as soon as the patient has any symptoms whatsoever," said cardiologist James D. Bergin, medical director of the heart failure/heart transplantation program at the University of Virginia, where they do about 35 LVAD implants a year.
"If we can do something to the heart that will make it recover, so that by putting in an LVAD you can actually turn it around, get the heart to recover and then take out the LVAD … then I think putting it in earlier is a good thing," Bergin said.
However, as long as the devices come with risks, it's better to proceed cautiously, Bergin said. All LVADs have bearings that wear out. They also have cables that come out of the body through a hole in the abdomen to connect to the power supply and controller. That opening is an infection risk.
"All of the LVADs currently have issues or troubles with stroke, because blood is flowing through an artificial surface," Bergin said.
Most of the data on LVAD use is on the sickest heart failure patients, Shah said. A large study that recently began seeks to compare LVAD use to drug therapy management in patients who aren't as sick as those waiting for transplants. About half of VCU's LVAD patients are waiting for transplants; others have it for long-term destination therapy.
"We should be cautious on two ends," Shah said. "Not to implant devices in people who are too sick, and we also should be cautious not to implant devices on people who are too healthy until the clinical trial is complete."
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Eva Ross, one of Zeevi's patients, has had an LVAD since early 2010. She was not eligible for a transplant because of other medical issues.
Her life is full, with family, church and volunteer work keeping her busy, she said. Two days a week she is at cardiac rehab.
"I still don't think I'm doing enough," said Ross, who lives in Sandston with her husband and other family members.
According to registry data, at two years out, 68 percent of patients with an implanted device were still alive.
Ross said before she had the implant, she slept in the bathroom, leaning on the sink because she would get breathless lying down. She is in a support group and says there are mixed feelings about the devices.
"I find that some LVAD patients are angry because they have to wear all this stuff," said Ross, referring to the harness and batteries.
"You shouldn't be," she said. "I tell people this is my lifeline."
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Heart failure
What it is: A condition in which the heart cannot pump enough blood to meet the body’s needs.
What causes it: Conditions such as coronary artery disease, high blood pressure and diabetes that damage or overwork the heart. Other causes include heart valve disease, cardiomyopathy, arrhythmias and congenital heart defects.
How common is it? About 5.8 million people in the United States have it. An estimated 670,000 new cases are diagnosed every year.
Symptoms: Shortness of breath during routine daily activities; having trouble breathing when lying down; weight gain with swelling of legs, ankles, abdomen or lower back; general fatigue and weakness.
How it is treated: Early diagnosis includes treating underlying causes. Lifestyle changes such as a heart-healthy diet, drinking correct amount of fluids, losing weight if overweight and quitting smoking can help. Oral medications may be prescribed. When those things no longer work, surgery is considered. Devices such as an implantable cardioverter defibrillator and pacemakers help some patients with specific types of heart failure. Ventricular assist devices, artificial hearts and heart transplant are considered for advanced heart failure.
How to prevent it: Follow a healthy diet. Quit smoking. Be physically active. Don’t use illegal drugs. Lose weight if overweight. Not all risks are modifiable.
Source: National Heart, Lung, and Blood Institute; National Institutes of Health; Centers for Disease Control and Prevention
Heart pump* use
in the United States
June 2006-September 2011
Gender: Male, 3,777; female 1,026
Age: 0-18, 61; 19-39, 668; 40-59, 2,174; 60-79, 1,883; 80+, 17
Race: American Indian or Alaskan Native, 25; Asian, 53; Black, 1,021; Hawaiian/Pacific Islander, 21; White, 3,388; Mixed race, other, unknown, 295
Device type: LVAD, 4,311; BiVAD, 385; total artificial heart: 107
Source: Interagency Registry for Mechanically Assisted Circulatory Support, Quarterly Statistical Report, Dec. 5. The registry is voluntary and does not capture all patients with devices.
Resources
American Heart Association: www.heart.org
NIH National Heart, Lung, and Blood Institute: www.nhlbi.nih.gov
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