Ventricular assist device implantation

Postcardiotomy failure (left ventricular assist device [LVAD])

• Elevated left atrial pressure (LAP) and cardiogenic shock despite inotropic support and intraaortic balloon pump (IABP)

  • LAP >25 mm Hg

  • Cardiac index (CI) <2 L/min/m ²

  • Severe left ventricular (LV) dysfunction on echocardiogram

  • Intractable ventricular arrhythmias

  • Ongoing myocardial ischemia despite revascularization

Postcardiotomy failure (bilateral ventricular assist device [BiVAD])

• Evidence of an elevated central venous pressure (CVP; >9 mm Hg) despite pulmonary afterload reduction

• Evidence of severe right ventricular (RV) dysfunction on echocardiogram

• Inability to provide adequate blood flow to fill the LVAD (if an LVAD is in place)

Bridge to cardiac transplantation

• Failure of optimal medical therapy that increases the risk of compromised life or end-organ function while awaiting cardiac transplantation

  • CI <2 L/min/m ²

  • Mixed venous oxygen saturation <50% on optimal medical therapy

  • Ventricular arrhythmias

  • Severe symptoms at rest

  • Need for multiple inotropic agents

  • Lack of response to diuretic medications, with a rising creatinine

  • Pulmonary artery hypertension

  • Cool and constricted extremities reflective of poor perfusion

  • Low blood pressure, resting tachycardia, rales, and/or distended neck veins

  • Laboratory evidence of prerenal azotemia, hepatic dysfunction, or coagulopathy

  • Requirement for supplemental oxygen

Bridge to bridge: in conditions of cardiogenic shock when indications for cardiac transplantation are not yet met but are potentially attainable

LVAD versus BiVAD

• BiVADs should be considered for:

  • Intractable ventricular tachycardia or fibrillation

  • Cardiogenic shock requiring resuscitation with extracorporeal membrane oxygenation (ECMO)

  • Cardiogenic shock with multiorgan failure

  • Pulmonary edema despite maximal medical therapy

  • Chronic RV failure with ascites, low pulmonary artery pressure, severe hepatic or renal dysfunction, and tricuspid insufficiency

  • Severe acute respiratory distress syndrome

  • Giant cell myocarditis

  • Large anterolateral myocardial infarction with involvement of the anterior right ventricle

  • RV infarction

Destination therapy

• Indicated for patients who meet the previous criteria for bridge to transplantation (BTT) LVAD candidacy but who are not eligible for transplantation based upon age, obesity, renal dysfunction that will not tolerate immunosuppressive agents, or other comorbidities suggesting that the risk of transplantation is unacceptable

• Patients with advanced heart failure (HF) symptoms (New York Heart Association [NYHA] class IIIB or IV) who meet at least one of these criteria:

  • Continued failure despite optimal medical management for at least 45 of 60 days

  • NYHA class III or IV status for at least 14 days and dependent on IABP for 7 days and/or inotropes for 14 days

  • Treated with angiotensin-converting enzyme (ACE) inhibitors or beta-blockers for at least 30 days and found to be intolerant of these medications

  • Maximal oxygen consumption (VO ₂ max) ≤14 mL/kg/min or ≤50% predicted VO ₂ max with exercise testing (unless testing is contraindicated because of class IV status)

Postcardiotomy failure

• Sepsis

• “Stone heart,” or lack of any innate cardiac function

• Age >70 years

• Condition in which recovery is not anticipated and the patient is not a candidate for cardiac transplantation

BTT

• Patient is not a candidate for cardiac transplantation

• Sepsis

• End-organ damage is not likely to recover

• Severe impairment of neurologic function

• Severe chronic obstructive pulmonary disease

• Procoagulation abnormalities, with previous venous or arterial thrombosis despite anticoagulation therapy

• Pregnancy

• Inability or refusal to receive blood transfusions

• Technical obstacles that pose an inordinately high surgical risk

Destination therapy

• Same as for transplantation, other than the requirement for cardiac transplantation candidacy

• Lack of social or family support that allows for home discharge

• Inability to comprehend plans for postoperative LVAD training

• Expected need for prolonged biventricular support

• Severe symptomatic peripheral vascular disease

• Intolerance to anticoagulant or antiplatelet therapies or any other perioperative or postoperative therapy the patient will require based upon his or her health status

• Psychiatric disease, irreversible cognitive dysfunction, or psychosocial issues likely to impair compliance with protocols and LVAD management