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.

Precision medicine, agriculture, and genome editing: science and ethics

“…From the humble Drosophila melanogaster to rodents to nonhuman primates, animal‐based research has yielded knowledge indispensable to our current understanding of medicine. More currently, a devastating, chronic illness, such as heart failure, whether of ischemic or nonischemic etiology, often leads patients to exceed the capacity of medical therapy to control their decompensations, and to require advanced therapies, including left ventricular assist devices (LVADs) and heart transplantation . Of these, only heart transplant offers a cure, though increasingly in some patients, LVADs are being used as destination therapy.…”

Invasive Treatment in Advanced (Stage-D) Heart Failure

“…Survival is lower in patients with valvular cardiomyopathy, congenital heart disease, or following retransplantation, and for those requiring pretransplant MCS. Additionally, patients who are sicker prior to transplant have worse survival outcomes [92]. Cardiac allograft vasculopathy is among the primary causes of death after the first year of HTx, and it is the most important limiting factor in long-term survival, along with neoplasms, with an incidence of 8% in the first year, 30% in 5 years, and 50% in 10 years [93].…”

Heart transplantation from older donors

“…Предполагалось, что сердца от доноров старших возрастных категорий, или так называемых возрастных доноров, более склонны к повреждению во время смерти мозга, фармакохолодовой консервации и последующей реперфузии, что может привести к выраженной ранней дисфункции трансплантата [1,2]. Однако за последние десятилетия отношение к выполне нию ТС от возрастных доноров стало меняться, что связано с ростом количества пациентов с застойной сердечной недостаточностью, нуждающихся в ТС, нехваткой донорских сердец и высокой летальнос тью в листе ожидания [3]. Даже в США, выполняю щих ежегодно около 1990 ТС, летальность потенци альных реципиентов на этапе ожидания донорского сердца составляет 15% [4].…”