-
Since the introduction of continuous-flow LVADs in the Netherlands in 2006, the number of implantations has increased substantially, outnumbering heart transplantation as treatment for advanced heart failure.
-
The results after LVAD implantation justify the use as an alternative to heart transplantation.
-
Currently, the four implanting centres (UMCU, EMC, UMCG and LUMC) have sufficient capacity for the LVAD implantations needed.
-
Early referral to an LVAD-implanting centre is mandatory for optimal timing and outcome of LVAD implantation.
Introduction
Indications for long-term MCS
-
Advanced heart failure with a low left ventricular ejection fraction <30% despite optimal therapy consisting of maximally tolerable medication with or without resynchronisation therapy and other interventions to optimise the cardiac condition, as indicated by the current heart failure guideline [2];
-
Exercise tolerance, assessed by cardiopulmonary exercise testing, reveals a peak VO2 <12 ml/min/kg (<14 ml/kg/min if intolerant to beta blocker) or <50% of the predicted value for age and sex in ambulatory patients: strong intrinsic motivation and Inter-agency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 2–6 (Tab. 1; [12])
NYHA class | INTERMACS profile | Popular term | BTT/DT | Prognosis |
---|---|---|---|---|
IV | 1. Critical cardiogenic shock | ‘Crash and burn’ | NO * | Hours to weeks |
IV | 2. Progressive decline | ‘Sliding fast’ | YES | |
IV | 3. Stable but inotrope dependent | ‘Stable dependent’ | YES | Weeks to months |
IV | 4. Recurrent advanced heart failure | ‘Frequent flyer’ | YES | |
IIIb–IV | 5. Exertion intolerant | ‘Housebound’ | To be considered | Months to years |
IIIb | 6. Exertion limited | ‘Walking wounded’ | To be considered | |
III | 7. Advanced NYHA III | NYHA class III | In the long term |
Contraindications for long-term MCS
1 | INTERMACS 1 (Cardiogenic shock) despite IABP, temporary MCS and/or inotropics |
2 | Life expectancy <2 years due to extracardiac disease |
3 | Severe comorbidity/end organ failure – Severe renal failure (estimated GFR <30 ml/min/1.73 m2), unlikely to improve after LVAD implantation – Severe liver failure/cirrhosis or portal hypertension, unlikely to improve after LVAD implantation – Severe pulmonary disease (with a FEV1 <1 liter), or pulmonary disease resulting in an important component of symptomatology that could result in de absence of improvement of symptoms after LVAD implantation – Severe central/peripheral artery disease and/or abdominal aorta >5 cm (untreated) – Symptomatic cerebral pathology in the recent 6 months and/or severe disability after neurological event and/or carotid artery stenosis >80% that cannot be treated – Severe neuromuscular pathology, limiting exercise capacity and/or ventilation postoperatively – Increased bleeding risk (which will not improve after LVAD implantation) a. Persisting thrombocytopenia (<50,000 × 109/l) b. Active bleeding c. Severe coagulopathy otherwise – Cognitive or psychosocial factors a. (Beginning) dementia b. Depression, unlikely to improve after LVAD implantation |
4 | Severe right heart failure, with a high risk for the need for right ventricular assist device (despite in BTT, implanting a biventricular assist device may be considered) |
5 | Phenotype of heart failure, in which implantation of a LVAD is impossible/complex: – Hypertrophic cardiomyopathy (unless, in dilating phase) – Restrictive cardiomyopathy/endomyocardial fibrosis – Complex uncorrected congenital heart disease/valvular disease |
6 | Difficulties in ventilation in intubated patients |
7 | Severe cachexia (BMI <18.5 kg/m2), unlikely to be corrected |
8 | Morbid obesity (BMI >35 kg/m2), uncorrected |
9 | (Increased risk for) systemic infection |
10 | Severely calcified ascending aorta (where outflow cannula is inserted; consider inserting the outflow cannula at another location) |
11 | Intolerance to coumarin derivates and/or thrombocyte aggregation inhibitors |
12 | Non-compliance, substance abuse (drugs/alcohol/nicotin) |
13 | Absence of social network, severe language barrier |
Patient selection
Survival
Adverse events
Infection
Right heart failure
Device malfunction
Bleeding
Stroke
Arrhythmias
Referral
-
Severely symptomatic: NYHA III+ to IV despite optimal heart failure treatment;
-
Relatively young patients with symptomatic heart failure;
-
Genetic cardiomyopathies with a likelihood of rapid progression of disease (e.g. PLN mutation);
-
Recurrent admissions for heart failure;
-
Inotrope dependency;
-
Difficulties in titration of heart failure medication (as a result of hypotension, renal failure, intolerance);
-
The need for high-dose diuretics (arbitrary >4 mg bumetanide/>160 mg furosemide).
I | Inotropics | Previous or current need for inotropics |
N | NYHA III–IV/Natriuretic peptides | Persisting NYHA III–IV or increased (NT-pro)BNP |
E | End-organ failure | Deteriorating kidney and/or liver function |
E | Ejection fraction | Severely depressed left ventricular function (ejection fraction <20%) |
D | Defibrillator shocks | Repeated ICD shocks |
H | Hospitalisations | More than 1 admission for heart failure in the last 12 months |
E | Edema or escalating diuretics | Persisting congestion or increasing diuretic dose |
L | Low blood pressure | Consistent low systolic blood pressure (<90–100 mm Hg) |
P | Prognostic medication | Inability to titrate evidence based medication (ACE inhibitor/ARB/beta blocker/MRA or ARNI) |