Abstract
Historically, cardiac transplantation is the only definitive therapy for mortality
reduction, symptom reduction, and improved quality of life in advanced heart failure.
Because of improvement in cardiovascular care there is now a growing number of patients
such as the elderly and those with abundant comorbidity who are not eligible for cardiac
transplant. Durable mechanical circulatory support is the new reality in the treatment
of advanced heart failure in this population subset. The left ventricular assist device
(LVAD) has evolved from humble origins as a short-term extracorporeal and pulsatile
device into a durable intracorporeal continuous flow device capable of providing permanent
support in the form of destination therapy (DT) LVAD. Data gathered from original
landmark clinical trials including Randomized Evaluation of Mechanical Assistance
for the Treatment of Congestive Heart Failure (REMATCH), and the Heart Mate II Trial,
and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS)
provide insight into the type of patient and the timing in which to consider DT LVAD
therapy. There are a number individual patient warning signs and symptoms that predate
clinical decline; thus, identifying individuals who might benefit from a DT LVAD strategy.
The adverse event burden that accompanies DT LVAD therapy cannot be ignored when considering
LVAD as an adjunct to ongoing medical therapy. Trends in patient selection regarding
mechanical circulatory support continue to evolve along with the technology. As more
clinical outcome data are gathered we will continue to refine our patient selection
criteria and timing of implant.
Résumé
Traditionnellement, la transplantation cardiaque est le seul traitement définitif
qui permet la réduction de la mortalité, la réduction des symptômes et l’amélioration
de la qualité de vie lors d’insuffisance cardiaque avancée. En raison de l’amélioration
des soins cardiovasculaires, il existe maintenant un nombre croissant de patients
telles les personnes âgées et les personnes ayant de nombreuses comorbidités qui ne
sont pas admissibles à la transplantation cardiaque. L’assistance circulatoire mécanique
durable est la nouvelle réalité du traitement de l’insuffisance cardiaque avancée
pour traiter ce sous-ensemble de la population. Le dispositif d’assistance ventriculaire
gauche (DAVG) qui à l’origine n’était qu’un dispositif pulsatile extracorporel à court
terme est devenu un dispositif intracorporel à débit continu durable capable de fournir
une assistance permanente sous forme de DAVG en traitement définitif (TD). Les données
qui ont été recueillies dans des essais cliniques originaux marquants incluant l’étude
REMATCH (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart
Failure), l’essai du Heart Mate II et le registre INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) donnent un aperçu du type de patients et du moment propice où considérer le DVAG
en TD. Il existe chez les patients de nombreux signes et symptômes précurseurs individuels
qui sont antérieurs au déclin clinique, ce qui par conséquent identifie les individus
qui pourraient profiter de la stratégie du DAVG en TD. Le fardeau des événements indésirables
qui accompagne le TD par DAVG ne peut être ignoré lorsque l’on considère le DAVG comme
un complément au traitement médical en cours. Les tendances dans la sélection des
patients concernant l’assistance circulatoire mécanique continuent à évoluer parallèlement
à la technologie. Lorsque plus de données sur les résultats cliniques seront recueillies,
nous continuerons d’affiner nos critères concernant la sélection des patients et la
détermination du moment propice à l’implantation.
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Article info
Publication history
Published online: January 02, 2014
Accepted:
December 27,
2013
Received:
December 11,
2013
Footnotes
See page 302 for disclosure information.
Identification
Copyright
© 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
