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
...essment...
...1. Current Recommendations for MC...
...CF/AHA 2009 HF guidelines
...sideration of a left ventricular assist...
...nsive HF practice guidelines...
...atients awaiting heart transplantation...
...anical assistance with an implantable LVAD may...
...with refractory HF and hemodynamic i...
...ian HF guidelines...
...y be offered to selected individuals with...
...idelines 2008/2010...
...t indications for LVADs and artific...
...h experience is limited, these dev...
...idered as DT to reduce mortality. ( B , IIa )7...
Recommendations for MCS
...commendations for...
...S for BTT indication should be considered fo...
...antation of MCS in patients before the develo...
...with a durable, implantable devic...
...ve rather than urgent implantation...
...gent nondurable MCS is reasonable in h...
...tients should be referred to a center with e...
...nts who are ineligible for heart transplanta...
...l assessment of RV function is recomm...
...term MCS is not recommended in patien...
Long-term MCS as a bridge to heart-kidney...
...ssment of nutritional status is recommend...
...atients with obesity (BMI ≥30 to ≥40 kg/m2) d...
...essment of psychosocial, behavioral, and envir...
...on of potential candidates by a multidisciplin...
Figure 1. Device Selection Flow Chart
...igure 1. Device Selection Fl...
Selecting a Treatment Regimen
...electing a Treatment Regi...
...vices Available for Short-Term MCSHaving t...
...3. Devices Approved by the FDA for...
...gure 2. MCS Dev...
...timal Timing for Mechanical Circulatory Support...
...nostic Determinants in Advanced HFHaving trou...
...ERMACS Clinical ProfilesHaving trouble view...
.... Indications and Contraindications to Durable...
...7. The Lietz-Miller Score for Preoperative Ev...
...8. In-Hospital Mortality Based on...