Heart failure mechanical circulatory support

Dipla K, Mattiello JA, Jeevanandum V, Houser SR, Margulies KB. Myocyte recovery after mechanical circulatory support in humans with end-stage heart failure. Circulation 1998 97 2316-2322... 

Owing to his tireless efforts, Brano became Associate Director of Transplant Research in 1998 and Director of the Center for Cardiac Support in 2005. In the latter capacity, he lectured and traveled extensively, sharing his knowledge and expertise about mechanical circulatory support, heart transplantation, and other heart failure therapies with colleagues and friends. 

Stage D heart failure includes patients with symptoms at rest that are refractory despite maximal medical therapy. This includes patients who undergo recurrent hospitalizations or cannot be discharged from the hospital without special interventions. These individuals have the most advanced form of heart failure and should be considered for specialized therapies, including mechanical circulatory support, continuous positive inotropic therapy, cardiac transplantation, or hospice care. The approach to treatment of patients with stage D heart failure is discussed in more detail in the section Treatment Advanced/ Decompensated Heart Failure. ... 

If there is dear evidence of worsening prompt hospital admission for intensive therapy is necessary. As the availability of a suitable donor heart is not predictable, hemodynamic deterioration is first treated with intravenous inotropic support. When the low-cardiac-output syndrome continues to be refractory, patients are put on a mechanical circulatory device for temporary mechanical support. This bridge to transplantation concept enables patient stabilization, withdrawal of intravenous medication (inotropic agents, catecholamines, calcium sensitizers) and rehabilitation (Antretter et al. 2002a). During chronic mechanical circulatory support a low level of exercise is possible and the patients are able to walk around, to leave hospital and sometimes they are followed up by heart failure specialists in an outpatient clinic. Nearly 25% of the most recent cohort transplanted from 1 January, 2001 to 30 June, 2003 were on some type of mechanical circulatory support (Taylor et al. 2004). 

Treatment strategies for progressive pulmonary venous hypertension should focus on treatment of the underlying disease. For patients with advanced decompensated systolic heart failure and secondary pulmonary hypertension, it is essential to reduce the pulmonary vascular resistance prior to heart transplantation to prevent acute RV failure of the donor heart. The use of continuous milrinone, occasionally nesirit-ide, and earlier intervention with mechanical circulatory device support (19) as a bridge to cardiac transplantation is considered a standard approach for this group of patients. Earlier intervention with valve repair or replacement for patients with mitral valve disease and aortic valve disease with associated pulmonary hypertension is recommended. 

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