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.