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 MCS...
...2009 HF guidelines...
...sideration of a left ventricular assi...
...comprehensive HF practice guidelines...
...tients awaiting heart transplantation who have...
...anical assistance with an implanta...
Patients with refractory HF and hemodynamic in...
...ian HF guidelines...
...be offered to selected individuals with end-st...
...guidelines 2008/201...
...nt indications for LVADs and artificial hearts in...
...gh experience is limited, these devices m...
...y be considered as DT to reduce mortality. ( B ,...
...mmendations for M...
...indication should be considered for tra...
...of MCS in patients before the developm...
...le, implantable device for permanent th...
...ective rather than urgent implantat...
...Urgent nondurable MCS is reasonable in hemodyn...
...hese patients should be referred to a center...
...ho are ineligible for heart transplantation be...
...ssment of RV function is recommended as...
...m MCS is not recommended in patients with...
...Long-term MCS as a bridge to heart-ki...
...nutritional status is recommended as...
...obesity (BMI ≥30 to ≥40 kg/m2) derive ben...
...ment of psychosocial, behavioral, and environme...
...ation of potential candidates by a...
...re 1. Device Selection Flo...
Selecting a Treatment Regimen
...lecting a Treatment Reg...
...es Available for Short-Term MCSHaving trouble...
...ces Approved by the FDA for Long-Term...
...igure 2. MCS De...
...gure 3. Optimal Timing for Mechanica...
...gnostic Determinants in Advanced HFHaving t...
Table 5. INTERMACS Clinical ProfilesHaving...
.... Indications and Contraindications to Durable...
...etz-Miller Score for Preoperative EvaluationHa...
...ital Mortality Based on the ADHERE...