Ventricular Assist Devices for Acute and Chronic Heart Failure
Despite therapeutic advances that improve longevity and quality of life, heart failure (HF) remains a relentless disease. At the end stage of HF, patients may become eligible for mechanical circulatory support (MCS) for the indications of stabilising acute cardiogenic shock or for chronic HF management. MCS use is growing rapidly in the USA and some countries of the European Union, especially in transplant-ineligible patients. In others, it remains largely a tool to stabilise patients until heart transplant. MCS comprises a heterogeneous group of temporary and durable devices which augment or replace the pumping function of one or both ventricles, with postimplant 2 year survival rivalling that of transplant in selected, lower-risk patients. In transplant-eligible and non-transplant-eligible patients, improvement in end-organ perfusion, functional capacity and quality of life have been noted. Even for optimal candidates, however, there are a host of potential complications that require constant vigilance of a coordinated care team. Recently, there has been official recognition of the importance of palliative care expertise in advance care planning preimplant and management of patients with ventricular assist devices at the end of their lives.
Heart Failure (HF) is acute and chronic, presenting with haemodynamic decompensation and life-threatening arrhythmias, and smouldering symptoms such as dyspnoea and fatigue. HF afflicts over 20 million persons worldwide. Over the last 25 years the prevalence has doubled and will double again between 2030 and 2040. Refractory symptoms afflict at least 5% of HF sufferers. After failing medical and cardiac resynchronisation therapies, patients with end-stage HF are considered for 'advanced therapies', including palliative inotropes, heart transplant and, increasingly, mechanical circulatory support (MCS).
MCS comprises a heterogeneous group of devices which augment or replace the pumping function of one or both ventricles, including temporary cardiac support (TCS) and durable assist devices. The use of durable LV assist devices (LVADs) in chronic HF has increased dramatically, with up to 2511 implants in 2013 in the USA. For many patients awaiting transplant and for many others in the USA and Europe who are not transplant-eligible, LVADs stabilise deteriorating haemodynamic and metabolic status and provide a long-term bridge for heart transplantation. The 2 year survival for a cohort of continuous flow LVAD patients with low-risk variables rivals that of cardiac transplantation. Studies have identified significant improvements in quality of life and functional capacity after LVAD implantation to a degree that is unrivalled with any other non-surgical HF therapy in refractory, advance New York Heart Association (NYHA) class IV patient populations. But there are patients who derive limited benefit, related to preimplant comorbidities that are independent of but may interact with post-LVAD complications (such as RV failure, bleeding, pump thrombosis, stroke and infection). Even for optimal candidates, this spectrum of potential complications requires constant vigilance and management by a coordinated care team. These complications and other complexities have led to recent recognition of the importance of palliative care expertise in caring for LVAD patients.
Abstract and Introduction
Abstract
Despite therapeutic advances that improve longevity and quality of life, heart failure (HF) remains a relentless disease. At the end stage of HF, patients may become eligible for mechanical circulatory support (MCS) for the indications of stabilising acute cardiogenic shock or for chronic HF management. MCS use is growing rapidly in the USA and some countries of the European Union, especially in transplant-ineligible patients. In others, it remains largely a tool to stabilise patients until heart transplant. MCS comprises a heterogeneous group of temporary and durable devices which augment or replace the pumping function of one or both ventricles, with postimplant 2 year survival rivalling that of transplant in selected, lower-risk patients. In transplant-eligible and non-transplant-eligible patients, improvement in end-organ perfusion, functional capacity and quality of life have been noted. Even for optimal candidates, however, there are a host of potential complications that require constant vigilance of a coordinated care team. Recently, there has been official recognition of the importance of palliative care expertise in advance care planning preimplant and management of patients with ventricular assist devices at the end of their lives.
Introduction
Heart Failure (HF) is acute and chronic, presenting with haemodynamic decompensation and life-threatening arrhythmias, and smouldering symptoms such as dyspnoea and fatigue. HF afflicts over 20 million persons worldwide. Over the last 25 years the prevalence has doubled and will double again between 2030 and 2040. Refractory symptoms afflict at least 5% of HF sufferers. After failing medical and cardiac resynchronisation therapies, patients with end-stage HF are considered for 'advanced therapies', including palliative inotropes, heart transplant and, increasingly, mechanical circulatory support (MCS).
MCS comprises a heterogeneous group of devices which augment or replace the pumping function of one or both ventricles, including temporary cardiac support (TCS) and durable assist devices. The use of durable LV assist devices (LVADs) in chronic HF has increased dramatically, with up to 2511 implants in 2013 in the USA. For many patients awaiting transplant and for many others in the USA and Europe who are not transplant-eligible, LVADs stabilise deteriorating haemodynamic and metabolic status and provide a long-term bridge for heart transplantation. The 2 year survival for a cohort of continuous flow LVAD patients with low-risk variables rivals that of cardiac transplantation. Studies have identified significant improvements in quality of life and functional capacity after LVAD implantation to a degree that is unrivalled with any other non-surgical HF therapy in refractory, advance New York Heart Association (NYHA) class IV patient populations. But there are patients who derive limited benefit, related to preimplant comorbidities that are independent of but may interact with post-LVAD complications (such as RV failure, bleeding, pump thrombosis, stroke and infection). Even for optimal candidates, this spectrum of potential complications requires constant vigilance and management by a coordinated care team. These complications and other complexities have led to recent recognition of the importance of palliative care expertise in caring for LVAD patients.
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