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Vital Signs

Summer 2011

Cardiac Care:

New High-Tech Devices Enable Patients with Advanced Heart Failure to Live Longer, More Active Lives


VS-Summer11-Cardiac CareCardiac transplantation and mechanical circulatory support devices offered at UCLA and other leading centers are enabling many advanced heart failure patients to live long and active lives with a disease that once had a bleaker outlook. However, major challenges still exist for this population, including the shortage of organ donors. Mario C. Deng, M.D., the new medical director of the Advanced Heart Failure, Mechanical Circulatory Support and Heart Transplant Program at Ronald Reagan UCLA Medical Center, recently spoke about these challenges, as well as the importance of a humanistic approach to high-tech medicine. Dr. Deng is best known for having conceived of and pioneered one of the seminal recent advances in heart transplantation, in close collaboration with UCLA and other leading academic U.S. heart transplant centers: the first U.S. Food and Drug Administrationapproved blood test to rule out cardiac rejection. Known as the Allomap test, it has reduced the number of invasive cardiac biopsies for heart transplant recipients by at least 25 percent.

Summarize where the most progress has been made in the 20 years you have been in the heart failure field.

Starting with the development in medical therapies, there has been a more complete understanding of what the dysfunction in heart failure is about — not seeing it only on the isolated organ level but taking the person as a complex, dynamic system and treating him or her accordingly. The field of mechanical circulatory support has been rapidly advancing over the last 20 years. These mechanical devices perform the heart’s pumping function for people whose own hearts have been irreversibly damaged; they can be used to keep someone alive while waiting for a heart transplant or as destination therapy for those who are not candidates for transplant. We have moved to more evidence-based, less-invasive types of assist heart pumps that are smaller, more durable and allow the patient much more freedom to move about. And, finally, in heart transplantation I think one of the most important advances is the introduction of noninvasive monitoring based on a simple genomic blood test. Not only does this expose patients to fewer of the invasive heart muscle biopsies, but now we are using this geneexpression profiling approach to safely reduce the dosage of immunosuppression therapy, thereby reducing side effects.

Given the shortage of organ donors, most patients who could benefit from a new heart will not be able to get one. What are the prospects for them in light of these advances?

In the Greater Los Angeles area, there are roughly 100,000 to 200,000 people with heart failure, and of those, at least 10,000 have advanced heart failure. Since the number of donor organs for heart transplantation is 100-200 a year, this leaves at least 9,800 persons who have to be treated in other ways. Assist heart pumps are moving rapidly from bulky, crisis-intervention treatments toward small, completely implantable devices that allow patients to return to a fairly normal life. Currently, the number of patients with lifetime-assist heart pumps is already similar to the number of patients with a heart transplant. In 10 years, we will probably have a fourth- or fifth-generation device with completely implantable assist heart pumps that stay in the body 10-20 years, along with a system for powering the devices through the unbroken skin, with a very low risk of infection. With that advance, similar to the evolution of pacemakers over the last 50 years, another 1,000 to 2,000 of these persons may choose to have a mechanical circulatory support device for their lifetime. But many of these individuals may also opt to live a life with less aggressive treatment options. That kind of informed patient preference has to be respected.

You have described your vision as humanistic and patient-centered. What does that mean to you?

The core of my clinical convictions is that high-tech modern medicine can be practiced in a humanistically sound way only if we empower patients and their families to make VS-Summer11-Dr. Dengdecisions, and that we physicians see ourselves not as gods or goddesses — the sole possessors of knowledge and truth — but as consultants in our patients’ decision-making process. I listen to you as the patient, clearly communicate different options for you based on my expertise and experience, and empower you as the patient to make an appropriate decision, in consultation with your family and other second opinions. Our goal is to recommend to our advanced heart failure patients various options in answer to their question: “Doc, which treatment concept gives me the best chance of growing old and living a good quality of life?”

Where do you derive the most personal satisfaction from your work in this field?

To have had the underlying vision and to have been intimately involved with the implementation of the first-in-history genomic heart transplantation test is certainly very rewarding. But the most rewarding moments for me are those times when I am interacting with my patients in a way that connects us as two individuals — not white coat and patient, but two human beings. This is the spirit in which we must conduct our high-tech modern medicine.

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