Mechanical and Surgical Options for Patients with End-Stage Heart Failure

Abstract

While heart failure medications, and in certain cases, cardiac resynchronization therapy or implantable cardiac defibrillators have improved quality of life and survival in heart failure patients, overall morbidity and mortality is still high [1]; refractory end-stage heart failure patients ultimately require either short or long-term mechanical circulatory support (MCS) or heart transplantation. While transplantation is the current gold standard and only definitive solution, the lack of available donor hearts and prevalence of significant comorbidities as contraindication to transplantation has led to growing use of MCS devices. Indeed, in patients with end stage heart failure considered too unstable to await a suitable donor organ, biventricular or left ventricular assist devices (LVADs) as well as total artificial hearts (TAHs) can be employed as bridge-to-transplantation therapy and have been shown to improve quality of life, survival-to-transplantation rates, and post-transplant survival [2, 3].

ACC/AHA guidelines state that general indications for referral for MCS include stage D patients who demonstrate LVEF <25% and NYHA class III-IV functional status in spite of guideline-directed medical therapy, with either high predicted 1–2 year mortality (based on reduced peak oxygen consumption or clinical prognostic scores) or continuous dependence on parenteral inotropic support [2]. Generally, patient selection should be a multidisciplinary decision involving advanced heart failure/transplantation cardiologists, cardiothoracic surgeons, nurses, social workers, and palliative care clinicians.

Mechanical circulatory support consists primarily of ventricular assist devices (VADs) and the newer Total Artificial Heart (TAH), of which the latter will be discussed in detail in Chap. 17. Overall, the optimal strategy should include implanting the ideal MCS device with the best durability and lowest incidence of adverse events and that provides satisfactory cardiac output for either one or both failing ventricles. This chapter aims to provide an overview of mechanical circulatory support devices and indications for their usage in end-stage heart failure patients.