The state of destination therapy for the treatment of congestive heart failure

Purpose of review Early anecdotal reports on destination therapy from the 1970s and 1980s preceded a growing experience in mechanical circulatory support as a bridge to transplantation, which provided the real foundation for destination therapy. The landmark REMATCH trial, although less than ideal, showed that ventricular assist device therapy was superior to optimal medical management, and enabled regulatory and reimbursement approvals, establishing a therapeutic alternative for end-stage heart failure. Recent findings Post-REMATCH experience has documented a slower adoption of destination therapy than expected, but demonstrated improved outcomes from the most active implant centers. Retrospective analyses of the growing database have allowed exploration of preimplant risk factors, which, with dissemination, will enable evidence-based patient selection and further outcome improvements. Summary Although acceptance of destination therapy by the medical I community in the United States has been slow, there has been progress in several important areas. Better recipient management, the evolution of multidisciplinary teams and recipient support networks have resulted in improved outcomes. Clinical trials of pulsatile and continuous flow pumps are underway in the United States, and of rotary pumps internationally, which will provide new and better alternatives. The regulatory process in the United States is unnecessarily burdensome; a more practical alternative is essential for the field to prosper.