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/VCȯ2 slope)
•Low peak Vȯ2 (<12-14 mL/kg/min)
•Low 6-min walk test distance
(<300 meters)
