Abstract
Left ventricular assist devices (LVADs) have revolutionized therapy for patients with Stage D heart failure (HF) with reduced systolic function providing not only improved survival benefits but also meaningful changes in quality of life and functional capacity. With technological advances and improved durability of devices, length of survival has significantly improved. With continued organ donor shortage, LVADs are frequently serving as a substitute for cardiac transplant as destination therapy, particularly among the elderly. Internists not only face the important challenge of identifying the patients in need referral for these advanced therapies, they are also faced with the challenges of taking care of these patients. This review will help the internists to better understand the present status, indications and advances in LVADs and also understand the complications and adverse effects associated with these devices.
Highlights
BackgroundThe incidence and prevalence of patients with heart failure (HF) is increasing at alarming rates
There are four major indications for the use of Left ventricular assist devices (LVADs): 1. Bridge to destination: this indication is for heart transplant patients who are either too sick to wait for the donor to be identified because of severe acute or acute on chronic HF, or have contraindications to transplantation
Destination therapy: LVADs are used as lifelong support as an alternative for transplantation for patients deemed ineligible for heart transplantation
Summary
The incidence and prevalence of patients with heart failure (HF) is increasing at alarming rates. Presence of mechanical aortic or mitral valve including planned conversion to bioprosthesis, platelet count < 100,000/ml, inability to perform 6 min walk test, IV inotrope within 45 days, existence of any MCS pregnancy, history of cardiac/other organ transplant, psychiatric disease, active uncontrolled infection, intolerance to anticoagulation, coronary revascularization within three months, GFR, 25 ml/min or need for renal replacement therapy, any condition that could limit survival to less than two years. DT: Destination therapy; ENDURANCE: A prospective, randomized, controlled, un-blinded, multi-center clinical trial to evaluate the HeartWare" ventricular assist system (VAS) for destination therapy of advanced heart failure; HM3: HeartMate; HMII: HeartMate II; HMVE: HeartMate VE; INTERMACS: Interagency registry for mechanically assisted circulation; INTrEPID: Investigation of nontransplant-eligible patients who are inotrope dependent; LVAD: Left ventricular assist device; MOMENTUM 3: Multicenter study of MagLev technology in patients undergoing mechanical circulatory support therapy with HeartMate; REMATCH: Randomized evaluation of mechanical assistance for the treatment of congestive heart failure; ROADMAP: Risk assessment and comparative effectiveness of left ventricular assist device and medical management in ambulatory heart failure patients; HMXVE: HeartMate XVE; LVEF: Left ventricular ejection fraction; COPD: Chronic obstructive airway disease; BMI: Body mass index. There are four major indications for the use of LVADs: 1. Bridge to destination: this indication is for heart transplant patients who are either too sick to wait for the donor to be identified because of severe acute or acute on chronic HF, or have contraindications (that are deemed transient) to transplantation
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