[Heart transplantation, cardiomyoplasty or artificial heart?].

This is a difficult question and the answer is uncertain. The authors review the state of the art of the three methods in 1993. Cardiac transplantation seems to have attained its maturity. The annual number of transplant operations is stagnant and the results progress little. Functional rehabilitation is excellent, the essential immunosuppression which has not changed in principle over the last 12 years, remains prejudicial. Cardiomyoplasty is an attractive concept with difficult surgical indications (Stage III, moderately dilated cardiomyopathy with good right ventricular function without arrhythmias, pulmonary hypertension or mitral regurgitation), a delayed efficacy, a hospital mortality comparable with that of transplantation and a similar survival rate. The objective results are not as good as the more subjective functional improvement. This limited experience (about 500 patients in 50 centers throughout the world, 70% of whom are European) should be continued and evaluated in the centers which initiated it. The artificial heart is only a temporary though essential therapeutic option in certain extremely urgent situations. It is a form of circulatory assistance, ranging from the simple univentricular accessory pump to the univentricular (Novacor) or biventricular (Jarvik) heart, in a rapidly evolving technology with problems of energy sources, marketing, cost and also clinical management which is often difficult especially with respect to coagulation. What do the next ten years hold in store for us? A nex immunosuppressor or the xenograft? A more efficient cardiomyoplasty with more precise medications? A totally implantable autonomous artificial heart? Can economic considerations accompany this development? This is undoubtedly the deepest source of concern for the future.