Advanced therapies

Advanced therapies

 

Many patients with HF progress into a phase of advanced HF, characterized by persistent symptoms despite maximal therapy. The prevalence of advanced HF is increasing due to the growing number of patients with HF, ageing of the population, and better treatment and survival of HF. Prognosis remains poor, with a 1-year mortality ranging from 25% to 75%.

Prognostic stratification is important to identify the ideal time for referral to an appropriate centre (i.e. one capable of providing advanced HF therapies), to properly convey expectations to patients and families, and to plan treatment and follow-up strategies.

 
ESC Table 13
 
ESC Figure 4

Mechanical Circulatory support can improve survival and symptoms of patients with advanced HF. The use of MCS should be considered for the different scenarios listed in the current ESC guidelines

Indications for short- and long-term MCS should be based on the INTERMACS profiles.

ESC Figure 5

Despite many prognostic parameters, predicting outcomes remains difficult and patients are often referred to advanced HF centres too late.

Identifying warning signs in patients with non-advanced symptoms may allow early referral so that MCS and heart transplantation may be offered before the development of end-organ failure

Banner, N., Bonser, R., Clarke, A et al (2011)
Banner, N., Bonser, R., Clarke, A et al (2011)
Banner, N., Bonser, R., Clarke, A et al (2011)

Contraindicators

If there is any clinical uncertainty, discussion with the regional on-call transplant team should be considered, however, there are some absolute contraindications to Ventricular Assist Device / Transplantation as listed below:

  • Active significant substance abuse;
  • Psychiatric illness that could jeopardise compliance (eg psychosis requiring treatment);
  • History of non-adherence;
  • Diabetes with microvascular complications (eg proliferative retinopathy, diabetic nephropathy etc);
  • Solid organ or haematological malignancy; or
  • Morbid Obesity. BMI >35 (only in exceptional circumstances would patients with BMI 32-35 be deemed appropriate); BUT
  • Systemic (AL) Amyloidosis. ATTRwt (Wild Type Transthyretin Amyloidosis) is not a contraindication.

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