Intermediate- and long-term mechanical circulatory support
- Emma Jane Birks, MD, PhD, FRCP
Emma Jane Birks, MD, PhD, FRCP
- Professor of Medicine
- University of Louisville
- Division of Cardiovascular Medicine
- Director of Advanced Heart Failure, Transplant and Mechanical Support
- Jewish Hospital & St. Mary's HealthCare
- Section Editors
- Donna Mancini, MD
Donna Mancini, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Icahn School of Medicine at Mount Sinai
- Sharon A Hunt, MD
Sharon A Hunt, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Heart Transplantation
- Professor of Medicine
- Stanford University School of Medicine
Medical therapy (including angiotensin converting enzyme inhibitors, beta blockers, and aldosterone antagonists), cardiac resynchronization therapy, and implantable cardioverter-defibrillators have improved the survival of many with heart failure with reduced ejection fraction (HFrEF), but there remains a large group of patients who have advanced heart failure with poor prognosis despite optimal medical therapy. Unfortunately, the numbers of useable donor hearts available to perform heart transplantation for these patients has not increased in the United States and has actually decreased in Europe over recent years and the supply is and will remain inadequate for the population who could benefit from heart transplantation. (See "Overview of the therapy of heart failure with reduced ejection fraction".)
Mechanical support of the circulation with left ventricular assist devices (LVADs) is a rapidly evolving field. LVADs are efficient devices that assist and support the circulation and they are being inserted into an increasing number of patients with advanced HFrEF. Mechanical circulatory support with a ventricular assist device (VAD) is a life-saving therapy for patients with decompensating advanced heart failure who fail to improve or stabilize with optimal medical therapy.
This topic will discuss intermediate- and long-term VAD therapy. Short-term mechanical support and practical management of long-term mechanical circulatory support are discussed separately. (See "Short-term mechanical circulatory assist devices" and "Practical management of long-term mechanical circulatory support devices".)
CATEGORIES OF USE
A VAD can be used as a bridge to cardiac transplantation (to sustain life until a donor heart becomes available), as a bridge to decision (regarding transplant eligibility), as destination (or permanent) therapy, or as a bridge to recovery of heart function. Most patients receiving mechanical cardiac support for these indications receive a left ventricular assist device (LVAD) with less than 15 percent receiving biventricular support in the form of biventricular device (BiVAD; left plus right ventricular support) or total artificial heart (TAH) .
Bridge to transplantation — Intermediate- or long-term left ventricular assist devices (LVADs) can be used as bridges to transplantation (BTT) in patients with advanced heart failure with deteriorating clinical status who are or may be candidates for heart transplantation but are too unstable to wait any longer without circulatory support. LVADs are inserted into patients who have worsening New York Heart Association (NYHA) Class IIIb or IV heart failure (table 1) often despite inotropic plus intraaortic balloon pump support. Such patients often also have end organ dysfunction or other potentially reversible medical conditions that may be temporary contraindications to cardiac transplantation (for which LVAD use may be considered a “bridge to candidacy” or “bridge to decision”) . Not only are LVADs life-saving in these deteriorating patients who might otherwise die before a donor heart becomes available, but they can also improve secondary organ function prior to transplantation, reduce pulmonary hypertension, and enable improvement in nutritional status, all of which are associated with improved post-transplant survival.
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- CATEGORIES OF USE
- Bridge to transplantation
- Bridge to decision
- Destination therapy
- Bridge to recovery
- DEVICE OPTIONS
- FIRST GENERATION DEVICES
- HeartMate I device
- Thoratec paracorporeal ventricular assist device (PVAD)
- SECOND GENERATION DEVICES
- HeartMate II
- Jarvik 2000
- Berlin Heart INCOR
- THIRD GENERATION PUMPS
- Heartmate 3
- BIVENTRICULAR SUPPORT
- Total artificial heart
- CLINICAL USE
- CLINICAL EVIDENCE
- As destination therapy
- As a bridge to transplantation
- As a bridge to recovery
- Biventricular support
- - Biventricular device
- - Total artificial heart
- - Comparison of type of biventricular support
- SUMMARY AND RECOMMENDATIONS