End-Stage Heart Failure Not The End?

End-stage heart failure may not mean the end. Some patients' hearts recover after a bold new treatment with a mechanical heart device and powerful drugs.

End-stage heart failure means a person's heart has "remodeled" — that is, it has suffered so much damage that it has changed shape. Such hearts barely work. More than half of people with end-stage heart failure die within a year or two.

Currently, people in this condition get in line for a heart transplant. While waiting for a transplant, some patients get help from a mechanical device called a left-ventricular assist device, or LVAD. LVAD implants take oxygen-rich blood out of the left side of the heart and pump it back through the body.

Usually, patients get worse the longer they are on an LVAD. But once in a while, a patient's heart shows signs of getting a bit better.

Can this process be helped along? Yes, finds a British research team led by Emma J. Birks, M.D., Ph.D., and Magdi H. Yacoub, M.D., of Imperial College, London, and the Royal Brompton and Harefield National Health Service Trust, U.K.

The researchers carefully selected 15 patients with end-stage heart failure who could be placed on an LVAD. Then they gave the patients powerful drugs to reverse the remodeling process that made their hearts worse. Once this happened, they gave the patients another set of drugs to keep their hearts from shrinking.

Eleven of the 15 patients recovered enough to have the LVAD devices removed.
One died in the process. Another died of lung cancer more than two years after the LVAD removal. A third patient had severe heart failure — following an episode of heavy drinking — 21 months after LVAD removal. He later had a successful heart transplant.
The eight remaining patients recovered and are leading active lives more than four years after LVAD removal.

"'End-stage' heart failure can be reversed," Yacoub says in a news release. "The heart has the capacity to regenerate itself." "This therapy has the potential to ease the pressure on the [heart-transplant] waiting list," Birks says in the news release. "[It] also offers patients a better alternative to a donor heart — their own, healthy heart."

Birks' report appears in the Nov. 2 issue of The New England Journal of Medicine.
In an editorial accompanying the report, University of Utah heart transplant experts Dale G. Renlund, M.D., and Abdallah G. Kfoury, M.D., note that the technique is still experimental. They also point out that patients in the study were carefully selected. None was elderly; all but two were younger than 50.

But, still, the editorialists call the results "tantalizing."

"Maybe, in some patients, the failing heart is not end-stage after all," they suggest.
A clinical trial testing the new technique will soon begin at medical centers in North America and Europe. It will be called the Harefield Recovery Protocol, or HARP study.

SOURCES: Birks, E. The New England Journal of Medicine, Nov. 2, 2006; Vol. 355: pp. 1873-1884. Renlund, D. and Kfoury, A. The New England Journal of Medicine, Nov. 2, 2006; Vol. 355: pp. 1922-1925. News release, Imperial College, London.

By Daniel DeNoon
Reviewed by Louise Chang, M.D