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
...ssessment
...ent Recommendations for MCS...
...2009 HF guidelines
Consideration of a left ventricular assis...
...SA comprehensive HF practice gui...
...ing heart transplantation who have beco...
...rmanent mechanical assistance with a...
...fractory HF and hemodynamic instability and...
...ian HF guidelines...
...ed to selected individuals with end-stage HF who a...
...guidelines 2008/20...
...rrent indications for LVADs and art...
...ience is limited, these devices may be cons...
...considered as DT to reduce mortality...
Recommendations for MCS
...ommendations for MC...
...cation should be considered for transplant-eligib...
...on of MCS in patients before the devel...
...ith a durable, implantable device for perman...
...her than urgent implantation of DT can be be...
...rable MCS is reasonable in hemodynamicall...
...These patients should be referred to a center wi...
...ients who are ineligible for heart transplantation...
...sment of RV function is recommended as pa...
...ong-term MCS is not recommended in p...
...term MCS as a bridge to heart-kidney transpla...
...ssessment of nutritional status is...
...s with obesity (BMI ≥30 to ≥40 kg/m2) derive...
...ssessment of psychosocial, behavioral, and environ...
...uation of potential candidates by a multidi...
Figure 1. Device Selection Flow Chart
...igure 1. Device Selection Flo...
Selecting a Treatment Regimen
...ng a Treatment Regimen...
...Devices Available for Short-Term MCSHaving trouble...
.... Devices Approved by the FDA for Long-Term MCSHa...
...gure 2. MCS Devices...
...igure 3. Optimal Timing for Mechanical Cir...
...nostic Determinants in Advanced HFHaving troub...
...ERMACS Clinical ProfilesHaving tro...
...6. Indications and Contraindications to Du...
...7. The Lietz-Miller Score for Preoperat...
.... In-Hospital Mortality Based on the ADHER...