Mechanical Circulatory Support
Key Points
Key Points
- Each year in the United States ~50,000 patients die of advanced heart failure (HF).
- Advanced HF patients are those with clinically significant circulatory compromise who require special care, including consideration for heart transplantation, continuous intravenous inotropic therapy, mechanical circulatory support (MCS), or hospice.
- Typically, such patients have symptoms at rest or with minimal exertion and cannot perform many activities of daily living.
- Commonly used objective measures of functional limitations include:
- Peak oxygen consumption (Vȯ2) ≤14 mL/kg/min (or <50% of expected)
- A 6-minute walk <300 meters
- Many have cardiac cachexia, are failing or intolerant of conventional HF therapy, and require repeated hospitalization for more intensive management.
- Advanced HF patients usually have a life expectancy of <2 years without heart transplantation or MCS.
- As the demand for long-term replacement of diseased hearts increases, there is a clear need for innovative, safe, and durable MCS to treat the growing population of patients with advanced HF.
- The recent development of smaller, more durable, and safer ventricular assist devices (VADs) has enabled MCS to emerge as a practical and effective form of therapy, either until heart transplantation can be performed (as bridge to transplantation [BTT]) or increasingly as an alternative to transplantation as destination therapy (DT).
- There are limited options for patients with advanced HF who are ineligible for heart transplantation, and these individuals face poor prognosis and limited quality of life. When contraindications present a barrier for heart transplantation, alternative surgical options should be considered, especially for the younger patient. Patients selected for DT may have significant improvement of heart transplantation contraindications and ultimately be selected for transplantation.
Assessment
...ssessment
...able 1. Current Recommendations for MCS...
.../AHA 2009 HF guideli...
...ration of a left ventricular assist devi...
...mprehensive HF practice guidelines...
...ients awaiting heart transplantation who have...
...ent mechanical assistance with an implant...
...with refractory HF and hemodynamic in...
Canadian HF gui...
MCS may be offered to selected indi...
...C guidelines 2008/2...
Current indications for LVADs and artificial heart...
...though experience is limited, these...
...AD may be considered as DT to reduce...
Recommendations for MCS
...mendations for MCS...
...for BTT indication should be considered for t...
...n of MCS in patients before the develo...
...S with a durable, implantable device for...
...rather than urgent implantation of DT can be bene...
Urgent nondurable MCS is reasonable in he...
These patients should be referred to a cente...
...are ineligible for heart transplanta...
...ul assessment of RV function is recomme...
...-term MCS is not recommended in patients...
...rm MCS as a bridge to heart-kidney trans...
...tritional status is recommended as part of...
...s with obesity (BMI ≥30 to ≥40 kg...
...nt of psychosocial, behavioral, and environment...
...potential candidates by a multidiscipl...
Figure 1. Device Selection Flow Chart
...re 1. Device Selection Flow Char...
Selecting a Treatment Regimen
...cting a Treatment Regimen...
...able 2. Devices Available for Short-Term MCSHavi...
...vices Approved by the FDA for Long-Ter...
Figure 2. MCS Dev...
...ure 3. Optimal Timing for Mechanical Circula...
Table 4. Prognostic Determinants in...
...le 5. INTERMACS Clinical ProfilesHavi...
...Indications and Contraindications to Durabl...
.... The Lietz-Miller Score for Preoperat...
...n-Hospital Mortality Based on the ADHERE CART...