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Mechanical Circulatory Support

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Key Points ÎÎEach year in the United States ~50,000 patients die of advanced heart failure (HF). ÎÎAdvanced HF patients are those with clinically significant circulatory compromise who require special care, including consideration for heart transplantation, continuous intravenous inotropic therapy, mechanical circulatory support (MCS), or hospice. ÎÎTypically, such patients have symptoms at rest or with minimal exertion and cannot perform many activities of daily living. ÎÎCommonly used objective measures of functional limitations include: •  peak oxygen consumption (Vȯ2) ≤14 mL/kg/min (or <50% of expected) •  a 6-minute walk <300 meters ÎÎMany have cardiac cachexia, are failing or intolerant of conventional HF therapy, and require repeated hospitalization for more intensive management. ÎÎAdvanced HF patients usually have a life expectancy of <2 years without heart transplantation or MCS. ÎÎAs the demand for long-term replacement of diseased hearts increases, there is a clear need for innovative, safe, and durable MCS to treat the growing population of patients with advanced HF. ÎÎThe recent development of smaller, more durable, and safer ventricular assist devices (VADS) has enabled MCS to emerge as a practical and effective form of therapy, either until heart transplantation can be performed (as bridge to transplantation [BTT]) or increasingly as an alternative to transplantation as destination therapy (DT). ÎÎThere are limited options for patients with advanced HF who are ineligible for heart transplantation, and these individuals face poor prognosis and limited quality of life. When contraindications present a barrier for heart transplantation, alternative surgical options should be considered, especially for the younger patient. Patients selected for DT may have significant improvement of heart transplantation contraindications and ultimately be selected for transplantation.

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