COMMENTARY

MOMENTUM-3: The Future of the LVAD Is Here and Now

Melissa Walton-Shirley, MD

Disclosures

March 13, 2018

Trialists and journalists, practitioners and bloggers really appreciate a soundly positive trial. MOMENTUM-3, presented at the American College of Cardiology 2018 Annual Scientific Sessions, fit that bill. The new HeartMate 3 (Abbott) soundly defeated its sister HeartMate II on the endpoints of survival (82.8% vs 76.2%), freedom from reoperation or pump removal (97.2% vs 75.5%), and freedom from stroke (89.1% vs 76.3%) in patients with severe heart failure (New York Heart Association class IIIB or IV).

I spoke with Dr Rob Dowling, former director of Heart Transplantation and Mechanical Circulatory Support at Jewish Hospital in Louisville, Kentucky, by phone today. Dowling has performed a multitude of cardiac surgeries and implanted several devices on my patients throughout the years.  He commented, "I think it's great data in terms of decreasing pump thrombosis. We won't likely see the HeartMate II implanted anymore." 

Though freedom from stroke was reduced, Dowling said, "The data on stroke is encouraging, but there was no difference in disabling stroke, which still represents an area for improvement and active research." Our discussion brought back memories of some of the patients I referred for the ultimate in device therapy. 

The Patients of Yesteryear

There was a beautiful but breathless young woman whose first presentation was a left ventricular ejection fraction of 10%. Her pale cool skin shouted impending doom as her husband searched my expression for any shred of hope. There was no sustaining her without a ventricular assist device, and fortunately she bridged beautifully from death to life to find a "perfect-match" heart 18 months later. That was 10 years ago; she is still doing well and served as a spokesperson for the HeartMate II before her heart transplant.

There was the middle-aged father with severe diabetes who was trying to make ends meet while struggling with a rebellious teenager. He died of driveline infection a few months after implant.  

I recalled the politician who would plug in at night and campaign by day as he ran for office a second time. His was a destination device because of age, severe peripheral vascular disease, and diabetes. He lost the election but won our hearts because he never seemed discouraged and lived every single day of his final 3 years to their fullest, enjoying his family and friends. He drove to my house one evening just to show me he could do it.  He mugged for the camera when I wrote an article about his remarkable life. His fate was also infection.

The country boy who ate too much bacon and posted every meal on Facebook holds a special place in my heart.  We limped along with a waxing and waning ejection fraction on a palate of nonischemic heart failure.  When he couldn't afford his meds,  we pieced together a drug regimen from whatever we could find from our sample cabinets. We filed compassionate need papers until finally he was able to get disability, working all the while at a job too strenuous for his condition. He posted his entire journey on Facebook and thanked everyone for his or her well wishes. His was a rocky 2 years until he died of multisystem organ failure. 

I remember my friend's father who had biventricular failure. His only choice for a device was the AbioCor heart. He wanted to "contribute something" to medical science.  His implant went smoothly — and for a single day he felt better than he had felt in 5 years, but the next morning he didn't wake up. A few weeks later he passed away. Though the AbioCor has gone the way of the dinosaur, the lessons we learned from that device have spurred research on devices currently in development.

Pioneers Who Moved the Needle

I felt an enormous amount of gratitude for our researchers at the end of the MOMENTUM-3 presentation. I admire all of the patients who were willing to gamble on the only chance they had at a full life or at least a little more life.  I appreciate the bravery and integrity of their families who were living examples of staying and loving "in sickness and in health." I learned so many of life's lessons from all of them.

For some people, the opportunity to receive a device was everything — for others it still wasn’t enough. Success, though, stands on the shoulders of failure.  Moving the needle forward is the very definition of MOMENTUM, and that momentum is the only reason that the future of the LVAD is here and now. 

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