The role of mechanical support and transplantation in treatment of patients with end-stage cardiomyopathy.

THERE IS NO DOUBT that at present cardiac transplantation is the only long-term palliative procedure available for patients with end-stage cardiomyopathy. When left ventricular assist devices and artificial hearts become totally implantable, the state of the art of heart transplantation, donor availability, and longterm results with artificial devices will dictate the relative use of each of the techniques. Total implantation and thus long-term use of artificial devices appears to be 5 to 10 years in the future. In the meantime, prolongation of life in patients with end-stage cardiomyopathy can be accomplished with cardiac transplantation. Timely identification of those patients with a prognosis for survival of less than 1 year, referral to an active cardiac transplantation program, and arrival of a suitable donor before the patient's demise must all occur for the patient to benefit from cardiac transplantation. In our experience from 1979 until the end of 1984, 21% (16/77) of those patients selected as possible cardiac transplant candidates died while awaiting the transplantation procedure. Temporary use of mechanical support in these patients might have allowed them to survive until the time of transplantation. Sufficient evidence currently exists to indicate that the temporary use of mechanical support is reasonable and indicated for such patients. Identification ofpatients with poor prognosis. End-stage cardiomyopathy constitutes a broad diagnostic category of patients suffering from myocardial dysfunction of diverse causes.' Most have four-chamber cardiac enlargement, decreased ejection fraction, decreased cardiac output, and elevated filling pressures.' About 75% of these patients have an extremely poor prognosis, whereas 25% may survive for an extended period.2 Criteria helpful in selecting those who have a poor