A 72-year-old man presents to a heart failure clinic for further evaluation of his progressive fatigue and dyspnea. He has a history of an ischemic cardiomyopathy with a severely reduced ejection fraction (EF <20%), which was originally diagnosed several years ago. He was initially maintained on optimal medical therapy for his cardiomyopathy and resultant heart failure (HF). Despite medical therapy, however, he has noted progressive exertional intolerance as well as several episodes of acutely decompensated HF in the past year requiring admission for intensification of HF medical therapies. After a thorough evaluation, he is felt to be a good candidate for a left ventricular assist device (LVAD). He subsequently undergoes successful implantation of an LVAD as destination therapy.
It is estimated that more than 5 million Americans have HF with more than 650,000 new patients being diagnosed annually. Of these patients, half are estimated to have heart failure with a reduced ejection fraction (HFrEF).1 Further estimations suggest 25% to 30% of these patients have either NYHA functional class III or IV HF. Within this subpopulation, approximately 150,000 to 250,000 patients may qualify for advanced HF therapies such as cardiac transplantation or LVAD support.2 Due to a relative paucity of suitable donor organs, the number of annual transplants performed in the United States has remained stable at around 2000.3 As such, transplantation does not represent a viable treatment option for the majority of advanced HF patients. This gap has led to the growth of ventricular assist devices (VADs) as standard therapy in the treatment of advanced HF.1
Advanced HF can be described qualitatively as persistent significant HF symptoms despite ongoing optimal medical therapy,1 or more objectively using specific criteria described in detail elsewhere.4 Additional criteria have been evaluated to identify high-risk HF patients that may benefit from an evaluation for additional therapies.5-7 Some of these criteria are noted in Table 39-1. Patients categorized with advanced HF are noted by the designation of the ACC stage D heart failure.1 For patients with an acceptable surgical risk, successful implantation of an LVAD can be expected to improve both survival as well as quality of life.8-12
Table 39-1High-Risk Heart Failure Features |Favorite Table|Download (.pdf) Table 39-1 High-Risk Heart Failure Features
Selected Criteria Used to Identify High-Risk Heart Failure Patients
HF symptoms that fail to respond to medical therapy (persistent NYHA class III or worse symptoms)
Intolerance to HF medications
Frequent HF hospitalizations
More than 2 in 3 mo
More than 3 in 6 mo
Need for inotropes during hospital stay
|Abbreviations: EF, ejection fraction; HF, heart failure. |
CLINICAL INDICATIONS FOR VENTRICULAR ASSIST DEVICES
Currently, VADs are used for primarily for 1 of 2 indications: bridge to transplant (BTT) or destination therapy (DT).2 For patients who are eligible for cardiac transplantation but are anticipated to have a long wait for a donor organ, are not immediately eligible for transplant due to relative contraindications, or may not survive the wait for a donor organ, an LVAD can be used until transplantation can occur (BTT indication). Patients for whom cardiac transplant is not an option can receive an LVAD as permanent therapy (DT indication). The majority of LVADs implanted in ...