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Cardio Diabetes Medicine 2017 377

Mechanical Circulatory Support for

Advanced Heart Failure

Dr. Liviu Klein MD, MS
Director, Mechanical Circulatory Support and Heart Failure Device Programs,

University of California San Francisco, San Francisco, CA, USA

Abstract: survival in this population. As result, the number of
Due to the marked increase in the number of ad- recipients bridged to transplant with ventricular as-
vanced (end stage) heart failure patients and the lack sist devices has increased dramatically over the last
of suitable donors to allow heart transplantation, the decade; in 2016, 51% of adult recipients in the United
majority of these patients do not survive. Recent im- States were bridged with ventricular assist devices,
provements in technology have allowed development compared to only 19% in 2000.
of durable ventricular assist devices that can support The clinical profile of the advanced heart failure pa-
an increasing number of patients for longer duration tients includes several of the following characteristics
of time while allowing restoration of fairly normal despite optimal medical and electrical therapies: (1)
quality of life. Over the past decade better patient severe symptoms with New York Heart Association
selection has resulted in improved outcomes, with 3- (NYHA) functional class IIIor IV, continuously for at
and 5-year survival approaching survival after heart least 2 months; (2) severe impairment of functional
transplantation in individuals older than 60 years of capacity demonstrated by either inability to exercise,
age. Better understanding of the relation between se- a 6-min walk distance below300 m, or a peak oxygen
verity of patient condition at the time of implant and consumption below 12-14 ml/kg/min; (3) recurrent ep-
outcomes has resulted in an increasing number of isodes of hospitalization with signs of fluid retention
patients in cardiogenic shock being supported with and/or peripheral hypoperfusion;(4) left ventricular
temporary mechanical circulatory support to allow for ejection fraction below 25-30%; (5) high left or right
restoration of multi organ function ventricular filling pressures with low cardiac output at

before the implantation of durable ventricular assist cardiac catheterization;and (6) evidence of systemic
devices. organ injury, in particular renal and hepatic dysfunc-
tions (elevated blood urea nitrogen, creatinine and
Manuscript: bilirubin levels). Two or more of these findings should
prompt referral to a specialized heart failure program
Introduction for considerationof advanced therapies.
Heart failure incidence and prevalence are increasing In order to further refine the prognosis and the risk
worldwide at staggering levels. Close to 40% of the of surgical intervention in advanced heart failure pa-
heart failure patients have heart failure with reduced tients, the Interagency Registry for Mechanically As-
ejection fraction, and 10% of these patients have sisted Circulatory Support (INTERMACS) scale assigns
advanced (end stage) disease,yielding an estimated patients into seven levels according to their hemody-
cohort of several hundred thousands patients world- namic profile and functional capacity (Table 1). Based
wide who have a high one-year mortality (over 30%) on this risk profile, the time frame for intervention
and can benefit of advanced therapies such as heart should be within hours (profile 1) ordays (profile 2), or
transplantation or ventricular assist devices.The num- more elective such as weeks to months (profiles 3-6).
ber of heart transplants performed worldwide is lim- During the first decade of modern circulatory sup-
ited to 5-6,000 due to donor availability highlighting port (2000-2010) the majority of patients implanted
the need for mechanical alternatives for improving with durable ventricular assist devices were profiles 1

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