Update on Mechanical Circulatory Support in Heart Failure
Update on Mechanical Circulatory Support in Heart Failure
The landmark findings of the post-REMATCH data highlighted the importance of nutritional parameters, haematological abnormalities, and markers of RV failure and end-organ dysfunction in determining mortality post-LVAD placement. These findings shone a new light on the original REMATCH trial, in that much of the early mortality could have been attributable to patient selection, as these patients were uniformly New York Heart Association (NYHA) functional class IV, with severely low cardiac indices (mean 1.9 l/min/m) and evidence of end-organ dysfunction (mean serum creatinine 180 μmol/l). In Leitz's univariate analysis of the post-REMATCH data, highly significant predictors for 90 day mortality post-LVAD placement were thrombocytopenia (<148 000/μl), low serum albumin (<3.3 g/dl) as a measure of nutritional deficiency, elevated aspartate aminotransferase (AST >45 U/ml) reflecting liver congestion, and low haematocrit (<34%). These findings have led to an increased awareness that the previous practice of LVAD implantation as a last resort in severely decompensated patients is not in their best interest, and that either LVADs should be considered earlier in the evolution of advanced heart failure, when nutrition and end-organ function are still optimal, or means should be taken to improve these factors preoperatively where possible.
(Enlarge Image)
Figure 2.
HeartMate and pulsatile pump.
Whether LVADs are implanted as destination therapy or as a bridge to transplant, full commitment from the patient and optimal support from family or other caregivers is essential. In this respect, the psychological and sociological milieu of the patient is critical and requires detailed assessment by specialised staff before LVAD implantation, as is routinely true in the consideration of patients for cardiac transplantation.
Patient Selection
The landmark findings of the post-REMATCH data highlighted the importance of nutritional parameters, haematological abnormalities, and markers of RV failure and end-organ dysfunction in determining mortality post-LVAD placement. These findings shone a new light on the original REMATCH trial, in that much of the early mortality could have been attributable to patient selection, as these patients were uniformly New York Heart Association (NYHA) functional class IV, with severely low cardiac indices (mean 1.9 l/min/m) and evidence of end-organ dysfunction (mean serum creatinine 180 μmol/l). In Leitz's univariate analysis of the post-REMATCH data, highly significant predictors for 90 day mortality post-LVAD placement were thrombocytopenia (<148 000/μl), low serum albumin (<3.3 g/dl) as a measure of nutritional deficiency, elevated aspartate aminotransferase (AST >45 U/ml) reflecting liver congestion, and low haematocrit (<34%). These findings have led to an increased awareness that the previous practice of LVAD implantation as a last resort in severely decompensated patients is not in their best interest, and that either LVADs should be considered earlier in the evolution of advanced heart failure, when nutrition and end-organ function are still optimal, or means should be taken to improve these factors preoperatively where possible.
(Enlarge Image)
Figure 2.
HeartMate and pulsatile pump.
Whether LVADs are implanted as destination therapy or as a bridge to transplant, full commitment from the patient and optimal support from family or other caregivers is essential. In this respect, the psychological and sociological milieu of the patient is critical and requires detailed assessment by specialised staff before LVAD implantation, as is routinely true in the consideration of patients for cardiac transplantation.
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