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

Assessment

Table 1. Current Recommendations for M...

...A 2009 HF guidelines...

...n of a left ventricular assist devi...

...prehensive HF practice guidel...

...aiting heart transplantation who have become refr...

...nt mechanical assistance with an implantable LVAD...

...ents with refractory HF and hemody...

...anadian HF guidel...

...may be offered to selected individuals...

...guidelines 2008/2010...

...ons for LVADs and artificial hearts in...

...h experience is limited, these devices may be...

...nsidered as DT to reduce mortality. ( B , IIa )7...


Recommendations for MCS

...mmendations for M...

...TT indication should be considered...


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


...a durable, implantable device for perm...


Elective rather than urgent implantatio...

...nondurable MCS is reasonable in hemodynamically c...

These patients should be referred to a center...


...ho are ineligible for heart transplantation be...


...nt of RV function is recommended as...

...is not recommended in patients with advanced ki...

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


...ssment of nutritional status is recommende...


...h obesity (BMI ≥30 to ≥40 kg/m2) derive...


...psychosocial, behavioral, and envir...


Evaluation of potential candidates by a...


Figure 1. Device Selection Flow Chart

...1. Device Selection Flow Ch...

Selecting a Treatment Regimen

...ing a Treatment Regimen...

...vices Available for Short-Term MCSHaving trouble...


Table 3. Devices Approved by the FDA for Long-Ter...


Figure 2. MCS De...


.... Optimal Timing for Mechanical Ci...


...ble 4. Prognostic Determinants in Adv...


...le 5. INTERMACS Clinical ProfilesHaving trouble...


...e 6. Indications and Contraindicati...


Table 7. The Lietz-Miller Score for Preoperative E...


...8. In-Hospital Mortality Based on the ADHERE CART...