Destination therapy

Destination therapy is a therapy that is final rather than being a transitional stage until another therapy—thus, in transportation metaphor, a destination in itself rather than merely a bridge or road to the destination. The term usually refers to ventricular assist devices or mechanical circulatory support to keep the existing heart going, not just until a heart transplant can occur, but for the rest of the patient's life expectancy. It is thus a course of treatment for severe (e.g., NYHA class IV/ACC stage D) heart failure patients who are not likely candidates for transplant. In contrast, bridge-to-transplant therapy is a way to stay alive long enough, and stay healthy enough, to await transplant while maintaining eligibility for transplant. Other "bridges" include bridge to candidacy, bridge to decision, and bridge to recovery.

Heart failure is a leading cause of death in industrialized economies. Among those suffering from serious heart illness some are, for a variety of possible medical circumstances, ineligible for a heart transplant. Destination therapy provides a possibility to extend their lives and improve their quality of life.

In addition, destination therapy may in some cases turn out to remedy the condition that excluded transplantation

Estimates place the population in the United States that may benefit from destination therapy at 50,000 – 100,000 patients per year. The addressable population outside of the US is thought be similar in size.

In order for a patient to be recommended for destination therapy with an LVAD, he/she will have presented with end-stage heart failure, and will be ineligible for a transplant due to age, additional health problems, or other complications. In addition, patients may be eligible who are not suitable for heart transplant suffer from other circulatory conditions unrelated to the heart.

In 2000, the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial was conducted. REMATCH was a multi-center study supported by the National Heart, Lung, and Blood Institute to compare long-term implantation of left ventricular assist devices with optimal medical management for patients with end-stage heart failure who require, but do not qualify to receive cardiac transplantation. Based on the results of this study, the U.S. Food and Drug Administration (FDA) granted a Premarket Approval for the Thoratec HeartMate XVE LVAD to be used for destination therapy. In addition, the Centers for Medicare and Medicaid Services expanded Medicare coverage to include such therapy.

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