Figure 3. Optimal Timing for Mechanical Circulatory Support
NYHA IIIa
Too ���well���
Functional Class
IM 7
IM 6
IM 5
Optimal
IM 4
IM 3
IM 2
Too sick
IM 1
Death
Time ���
Table 4. Prognostic Determinants in Advanced HF
Demographic
���Advanced age
���Male sex
Clinical
���Frequent hospitalizations (>1 in past 6 mo)
���Hypotension
���Advanced NYHA class (III or IV)
���Failed CRT
���Intolerance to neurohormonal antagonists
���Inotrope dependence
���Increased diuretic requirement
���Comorbidities (eg, diabetes mellitus,
anemia, COPD)
Laboratory
���Hyponatremia
���Hepatic insufficiency
���Renal insufficiency (BUN/serum creatinine)
���Elevated neurohormones, natriuretic peptides,
troponins, CRP
Doppler echocardiography and right-heart catheterization
���Low LVEF (<30%)
���Low RVEF
���Mitral regurgitation/increased left atrial volume ���Increased pulmonary vascular resistance
���Increased filling pressure (PCWP >16 mm Hg or RAP >12 mm Hg)
Functional capacity
���Inability to perform an exercise test
���Increased ventilatory response to exercise
(VE/VC��2 slope)
���Low peak V��2 (<12-14 mL/kg/min)
���Low 6-min walk test distance ���
(<300 meters)
