Replacement of the failing heart

Heart transplantation is an effective means of treating patients with severe congestive heart failure. Following heart transplantation, the 1-year survival rate is now greater than 80%, and the 5-year survival rate is more than 60% at major medical centers. More than 1,200 heart transplants were performed in more than nine countries worldwide in 1985. The failure of medicare to pay for this procedure is no longer defensible on medical grounds. The argument in favor of medicare funding for heart transplantation is at least as compelling as that for kidney dialysis, the treatment of cancer, or AIDS. The limited availability of donor organs (at most, 1300-2000/year) is likely to place a finite constraint on the number of heart transplants that can and will be performed. Although combined heart-lung transplantation is feasible therapy for certain patients with severe pulmonary hypertension, the availability of suitable donors poses an even greater restriction on this procedure. Totally implantable ventricular assist devices are on the horizon. These devices have the potential for helping 17,000 to 35,000 patients annually at an estimated cost to society of $2.5 to $5 billion per annum. The development and use of such extremely expensive technology poses major socioeconomic and ethical questions for society.