Mechanical Circulatory Support

Publication Date: October 29, 2012

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

...sessment

...1. Current Recommendations for MC...

...CCF/AHA 2009 HF guideli...

...of a left ventricular assist device (LVAD)...

...mprehensive HF practice guideli...

...iting heart transplantation who have becom...

...anical assistance with an implantable LVAD may...

...tients with refractory HF and hemodynamic instab...

...dian HF guidelines

...offered to selected individuals wi...

...delines 2008/2010...

...indications for LVADs and artificial hearts in...

...perience is limited, these devices may be con...

...ay be considered as DT to reduce mortality. ( B ,...


Recommendations for MCS

...mendations for MCS...

...BTT indication should be considered for tr...


...n of MCS in patients before the development of...


MCS with a durable, implantable device...


...rather than urgent implantation of DT can be b...

...Urgent nondurable MCS is reasonable in hemodynami...

...nts should be referred to a center with expe...


...o are ineligible for heart transplantation bec...


...ment of RV function is recommended as...

...Long-term MCS is not recommended in patients with...

...CS as a bridge to heart-kidney tran...


...sessment of nutritional status is r...


...ents with obesity (BMI ≥30 to ≥40...


...essment of psychosocial, behavioral,...


...of potential candidates by a multidisci...


Figure 1. Device Selection Flow Chart

...e 1. Device Selection Flow Chart...

Selecting a Treatment Regimen

...ing a Treatment Regimen

...evices Available for Short-Term MCSHav...


...ces Approved by the FDA for Long-Term MCSHaving tr...


...ure 2. MCS Devices...


...imal Timing for Mechanical Circula...


.... Prognostic Determinants in Advanc...


...e 5. INTERMACS Clinical ProfilesHaving trouble...


...ndications and Contraindications to Durable Mechan...


...etz-Miller Score for Preoperative EvaluationHaving...


...8. In-Hospital Mortality Based on the AD...