Advanced therapies for end-stage heart failure

Abstract

Management of the advanced heart failure patient can be complex. Therapies include cardiac transplantation and mechanical circulatory support, as well inotropic agents for the short-term. Despite a growing armamentarium of resources, the clinician must carefully weigh the risks and benefits of each therapy to develop an optimal treatment strategy. While cardiac transplantation remains the only true "cure" for end-stage disease, this resource is limited and the demand continues to far outpace the supply. For patients who are transplant-ineligible or likely to succumb to their illness prior to transplant, ventricular assist device therapy has now become a viable option for improving morbidity and mortality. Particularly for the non-operative patient, intravenous inotropes can be utilized for symptom control. Regardless of the treatments considered, care of the heart failure patient requires thoughtful dialogue, multidisciplinary collaboration, and individualized care. While survival is important, most patients covet quality of life above all outcomes. An often overlooked component is the patient's control over the dying process. It is vital that clinicians make goals-of-care discussions a priority when seeing patients with advanced heart failure. The use of palliative care consultation is well-validated and facilitates these difficult conversations to ensure that all patient needs are ultimately met.

Fig. (1)

Survival after cardiac transplantation as reported by the International Society of Heart and Lung Transplantation (ISHLT). (A) Posttransplant survival by era for transplant recipients, January 1982-June 2010. (B) Conditional post-transplant survival by era for transplant recipients who survived to 1 year, January 1982-June 2010. Figures are obtained with permission from www.ishlt.org [2].

Fig. (2)

Important historical events in the evolution of LVAD technology for patients with advanced heart failure.