Current Approach to Heart Failure by Maria Dorobanţu Frank Ruschitzka & Marco Metra

Author:Maria Dorobanţu, Frank Ruschitzka & Marco Metra
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Patient Selection

As previously described in this chapter, the patients most likely to benefit from long-term use of ventricular assist devices are patients with advanced heart failure, preferably INTERMACS profiles 3–4, where the surgical risk of implantation is fairly small (in-hospital mortality less than 3–5 %). Patients with INTERMACS profiles 1–2 should be bridged with temporary mechanical circulatory support devices and their end-organ function and nutritional status improved significantly or normalized in order to decrease the surgical mortality and morbidity associated with the durable ventricular assist devices implant.

Ideal candidates are patients with large left ventricles, relatively preserved right ventricular function, elevated left ventricular filling pressures and low cardiac output, with competent aortic valve, without history of gastrointestinal bleeding, compliant, with adequate social support, and with few extracardiac comorbidities that could limit the long-term benefit of ventricular assist devices [30, 31]. Carefully selected patients with restrictive cardiomyopathy [32], incessant ventricular tachycardia or congenital heart disease [33] could also benefit from ventricular assist device implantation.

In our center, the absolute medical contraindications to implantation include recent stroke (within 3 months), active systemic infection, uncorrectable peripheral vascular disease or aortic disease, severe irreversible lung disease (forced expiratory volume in first second less than 1 L or diffusing capacity of the lungs for carbon monoxide less than 35 % of predicted values), severe cardiac cachexia (body mass index below 19 kg/m2, serum albumin level below 2.5 g/dL, or serum pre-albumin level below 15 mg/dL), end stage renal disease on dialysis or with high likelihood of needing dialysis post implant (e.g. creatinine above 3 mg/dL, unless the patient is considered as bridge to heart-kidney transplantation), biopsy proven liver cirrhosis, active or recent history (within 3 months) of heparin induced thrombocytopenia, irreversible cognitive dysfunction (as established by formal neurocognitive testing) and marked frailty [31]. Patients are also deemed to not be good candidates for implantation if they lack social support or have a recent or active history of significant alcohol or illicit substance use. Older patients (older than 80 years) or morbidly obese patients (body mass index above 45 kg/m2) are evaluated on case-by-case basis.

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