Heart failure continues to be associated with high morbidity and mortality. Over the past decade, left ventricular assist devices have been shown to improve the survival and quality of life. However, it is quite clear that very sick patients do not do as well, and it is therefore imperative to select patients at the proper time. In this article, we review both the indications for considering left ventricular assist device therapy as well as discuss the considerations and therapy that should be done pre-operatively to possibly improve post-insertion outcomes.
"While numerous risk stratification schemes exist, none of them perfectly predict disease progression or risk of morbidity and mortality, particularly not for individual patients. Identifying clinical inflection points necessitating MCS and cardiac transplantation thus remains more of an art than a scientific decision, leading to tremendous practice pattern variation among physicians  . "
[Show abstract][Hide abstract] ABSTRACT: Advanced heart failure describes the subset of heart failure patients refractory to conventional medical therapy. For some advanced heart failure patients, the use of mechanical circulatory support provides an intermediary “bridge” step for transplant eligible patients or an alternative therapy for transplant ineligible patients. Over the past 20 years, clinical observations have revealed that approximately 1% of patients with mechanical circulatory support undergo significant reverse remodeling to the point where the device can be explanted. Unfortunately, it is unclear why some patients experience durable, sustained myocardial remission, while others re-develop heart failure (i.e. which hearts “hold” and which hearts “fold”). In this review, we outline unmet clinical needs related to treating patients with mechanical circulatory support, provide an overview of protein dynamics in the reverse remodeling process, and propose specific areas where we expect mass spectrometry and proteomic analyses will have significant impact on our understanding of disease progression, molecular mechanisms of recovery, and provide new markers with prognostic value that can positively impact patient care. Complimentary perspectives are provided with the goal of making this important topic accessible and relevant to both a clinical and basic science audience, as the intersection of these disciplines is required to advance the field.This article is protected by copyright. All rights reserved
[Show abstract][Hide abstract] ABSTRACT: A great number of patients suffer and die of the sequelae of acute and chronic heart failure each year. Although advances in medical and surgical therapy have benefited many of these patients, most have disease that is refractory to any definitive therapy. For these patients cardiac transplantation is the only remaining hope. Unfortunately, because of the increasing demand for donor organs in the face of a fixed and limited supply, this option is available to only a small percentage of these patients. Even in patients accepted for transplantation, a significant waiting list mortality has been observed. A variety of VADs have been developed since the first successful case of mechanical cardiac assistance more than 30 years ago. These devices differ in basic mechanical function, method of insertion, and degree of implantability and thus have different indications and potential applications. Whereas the intraaortic balloon pump and centrifugal pumps are effective short-term support modalities, extracorporeal and implantable pulsatile devices have been used successfully for long-term support of patients with reversible and nonreversible cardiac failure. Although these pumps have most commonly been used as bridges to transplantation, increasing clinical experience has supported the notion of long-term mechanical assistance as a definitive therapy for patients with end-stage heart disease. Although complications, particularly infection and thromboembolism, pose significant challenges and long-term device reliability remains to be fully determined, available implantable devices appear to be capable of providing effective long-term support. As data are obtained from currently ongoing trials comparing VAD support with medical therapy for end-stage heart failure, ethical and economic issues will assume increasing importance.
Current Problems in Surgery 05/1997; 34(4):317-86. DOI:10.1016/S0011-3840(97)80014-7 · 1.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the perioperative period, acute heart failure can result from a variety of conditions, and treatment may vary considerably depending on its mechanism. This review aims to provide conceptual framework by selectively presenting recent knowledge and advances in acute heart failure therapies including drugs (inotropes, diuretics) and devices (mechanical assistance, biventricular pacing, ultrafiltration).
The calcium sensitizer levosimendan, showed a mortality benefit in cardiac surgery patients in a recent meta-analysis. A study involving patients with cardiogenic shock complicating myocardial infarction for which early revascularization was planned, intra-aortic balloon support did not reduce 30-day mortality. A novel study showed that ultrafiltration was inferior to pharmacologic therapy in acute heart failure in nonsurgical patients. Biventricular pacing provided a significant clinical benefit over right ventricular pacing in nonsurgical patients with left ventricular dysfunction and atrioventricular block. Two recently published meta-analyses confirmed the prognostic role of natriuretic peptides in the perioperative setting.
Poor data exist in the perioperative setting concerning acute heart failure therapies. Large trials are needed to support the use of levosimendan, mechanical assistance, utrafiltration and biventricular pacing in the perioperative setting. The prognostic role of natriuretic peptides was confirmed in the perioperative period.
Current opinion in anaesthesiology 02/2014; 27(2). DOI:10.1097/ACO.0000000000000056 · 1.98 Impact Factor
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