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
...Assessment...
...Table 1. Cur...
...on of a left ventricular assist dev...
...HFSA...
...ents awaiting heart transplantation who...
...ent mechanical assistance with an impla...
...with refractory HF and hemodynami...
...Canadian HF guidelin...
...be offered to selected individuals w...
...ESC gui...
...ications for LVADs and artificial hearts inc...
...perience is limited, these devices may...
LVAD may be considered as DT to reduce mo...
Recommendations for MCS
...Recommendati...
...ication should be considered for transpla...
...ion of MCS in patients before the development...
...urable, implantable device for permanent th...
...er than urgent implantation of DT can...
...nt nondurable MCS is reasonable in hemodynamica...
...e patients should be referred to a center...
...nts who are ineligible for heart transplant...
...sessment of RV function is recommended as...
...g-term MCS is not recommended in p...
...g-term MCS as a bridge to heart-kidney t...
...sessment of nutritional status is recommended as p...
...h obesity (BMI ≥30 to ≥40 kg/m2) derive...
...essment of psychosocial, behavioral, and en...
...of potential candidates by a multidiscipli...
Figure 1. Device Selection Flow Chart
...Device Selection Flow Chart...
Selecting a Treatment Regimen
...Selecting...
...2. Devices Available for Short-Term MC...
...ices Approved by the FDA for Long-Term...
Figure 2. MCS De...
...re 3. Optimal Timing for Mechanical Circulator...
...Prognostic Determinants in Advanced HF...
...TERMACS Clinical Profiles Level...
.... Indications and Contraindications to Durabl...
Table 7. The Lietz-Miller Score for Preope...
...In-Hospital Mortality Based on the ADHERE CART M...