Advanced heart failure: LVAD and heart transplantation

Heart failure is often a chronic and progressive disease, characterized by an unpredictable and variable course of the disease in different patients. As the disease progresses, the symptom burden increases, often with a complex contribution of comorbidities.

Despite optimal treatment, some patients will still progress to severe and persistent highly symptomatic heart failure. This is then referred to as advanced heart failure.

It is the task of the cardiologist to recognize the stage of advanced heart failure through multiple criteria, based on symptoms, clinical evolution, echocardiography, exercise test (cyclo-ergospirometry, CPET, VO2max),...

These patients have a poor prognosis over a period of months to a few years. Heart replacement therapy may be a good option for a very selective group of these patients.

There are two types of advanced heart replacement therapy:

Implantation of a heart pump. LVAD, left ventricular assist device.
Heart transplant.

LVAD, left ventricular assist device. Type: Heartmate II. 1. Pump, 2. the driveline (the cable that connects the implanted pump to the controller and the external batteries), 3. External batteries.

It is very important that the treating cardiologist always correctly assesses the prognosis and discusses this with the patient and, if desired, with the family. Doctors and healthcare providers must ask the patient's therapeutic wishes in a timely manner, especially in the event of a deterioration of the clinical condition. In addition, it must be evaluated in a timely manner whether the patient could still be considered for a heart transplant.

If the patient is no longer a good candidate for this, or if the patient no longer wants a heart transplant, at a certain point there are no more therapeutic options and terminal heart failure can be considered. This is the end stage of heart failure with poor general or functional condition of the patient (NYHA class III to IV) and limited therapeutic options, without the patient still being eligible for LVAD (left ventricular assist device) and heart transplantation. From then on, the emphasis is on medicinal policy and comfort therapy.

Read : What to do in advanced heart failure / terminal heart failure?

If the patient with advanced and maximally treated heart failure is still a candidate for heart replacement therapy and if the patient still wishes to do so, the patient must be referred in a timely manner to a transplant center for further evaluation with an extensive pretransplant assessment. After approval by the transplant team, the patient can be actively placed on the waiting list for transplantation.

In some cases, heart failure can be so severe and life-threatening that urgent referral to a transplant center is necessary, if necessary after initiation of ECMO. This may involve, for example, acute heart failure due to a large myocardial infarction or myocarditis. Or progressive heart failure with very severely reduced LVEF and presentation with cardiogenic shock.

Indications for referral to a heart transplant center

Elective (short term)

Referral for screening for a possible heart transplant is indicated if:

Optimized heart failure treatment (medication and devices) confirmed by the heart failure team
Persistent severe heart failure symptoms NYHA III (not being able to climb 1 floor of stairs without symptoms) or NYHA IV
Severe and irreversible cardiac dysfunction
- LVEF < 30%
- severe right ventricular dysfunction
- inoperable severe valve dysfunctions
- inoperable serious congenital heart defects
- persistently high NT-proBNP values with evidence of severe diastolic dysfunction
Documented severe limitation of exercise capacity
- 6 min walking test < 300m
- peak VO2 < 12 ml/kg/min or < 50% of predicted value
Repeated admissions for cardiac decompensation in the last 12 months requiring intravenous diuretics (due to congestion) and/or inotropics (due to low output)
Need for a high maintenance dose of diuretics (> 2 mg bumetanide or 80 mg furosemide per day)
Intolerance to heart failure medication requiring reduction of therapy due to hypotension, deterioration of renal function, etc.
Frequent episodes of ventricular arrhythmias and ICD shocks despite optimal medication and possible VT ablation

Urgent

Urgent referral to a hospital where LVAD implantation and heart transplantation is performed is indicated in acute presentations of very severe heart failure with a risk of fatal outcome (pre-shock or shock) and possible need for temporary or permanent mechanical circulatory support.

Need for continuous inotropics, IABP or ECMO to prevent multiple organ failure (MOF).
Cardiogenic shock with persistent coronary ischemia without options for revascularization
Persistent cardiogenic shock
Therapy-resistant VT storm

With also the absence of a contraindication for heart transplantation.

The treating cardiologist must assess the potential for advanced therapy based on age, history and comorbidities, the severity of the clinical presentation with attention to neurological status and end-organ functions.

If there is still potential for heart replacement therapy or in case of doubt, immediate consultation (7/7 days 24/24 hours) should always be made with the heart team of a heart transplant center.

The indications for a possible referral can also be summarized in the acronym “I NEED HELP”.

When is a patient no longer eligible for a heart transplant?

A patient is no longer eligible for a heart transplant if:

Age over 65 years. The biological age and general condition of the patient are also taken into account. If necessary, consult with the transplant center.
Severe peripheral or cerebrovascular disease, a stroke with lasting significant sequelae.
Severe COPD.
Severe, fixed pulmonary hypertension.
Active malignancy or treated malignancy with a risk of recurrence (to be determined by the treating oncologist).
Active infections, positive HIV serology.
Irreversible renal insufficiency (eGFR < 45 ml/min), nephrological advice required.
Any non-cardiac pathology with a significant negative impact on life expectancy and/or quality of life.
Obesity with pre-transplant BMI > 30 kg/m2.
General weakness and cachexia.
Active alcohol abuse, drug abuse, active smoking.
Psychosocial instability (advice from a psychologist and/or psychiatrist).
Lack of capacity, lack of therapy compliance, lack of insight into the disease, lack of social support. This is a team decision between the general practitioner, the treating cardiologist, the transplant team, a psychologist with expertise in transplant care and social services.
Multiple previous cardiac procedures that complicate cardiac surgery.

LVAD as a bridge to transplantation

The average waiting time between activation on the transplant waiting list and the date of the transplant is often long, on average 1 year. If the hemodynamic status is too poor at the time of activation on the waiting list, it is sometimes opted to implant an LVAD to bridge the time until transplantation as best as possible (bridge-to-transplantation) in order to keep the patient alive and healthy. to maintain the best possible condition until the moment of transplant.

Other additional reasons for LVAD as a bridge-to-transplantation may include:

Renal function impairment caused by heart failure, which may be expected to recover after hemodynamic improvement (normal urine sediment, normal renal imaging).
Heart failure-induced pulmonary hypertension, which can be expected to sufficiently reduce pulmonary pressures after hemodynamic improvement.

LVAD as destination therapy

Some patients are no longer good candidates for heart transplantation, but are still too good for palliative management alone. After evaluation in a transplant center, these patients can be considered for an LVAD as definitive treatment (destination therapy).

The criteria for this are:

1) The patient is no longer eligible for a heart transplant.

2) The patient has persistent severe and disabling heart failure symptoms (NYHA III (inability to climb 1 floor of stairs without symptoms) or NYHA IV), despite optimal medical and device therapy.

3) The patient has at least one of the following:

Documented severe limitation of exercise capacity
- 6 min walking test < 300m
- peak VO2 < 12 ml/kg/min or < 50% of predicted value
3 or more admissions for acute heart failure in the past year
Increasing renal insufficiency due to heart failure (due to congestion/ hypotension/ hypoperfusion)
Threatening ventricular arrhythmias (VT/VF) despite maximum treatment with medication and, if possible, ablation.
Poor quality of life due to heart failure (score 50 or less out of 100 according to EQ5d questionnaire)
Clinical need for tapering heart failure medication due to hypotension/loss of renal function

4) The patient does not have any of the following major contraindications to LVAD:

Heart failure with preserved LVEF or undilated left ventricle
Presence of metal artificial valves
Isolated or dominant right heart failure
Age 70 years or older
Obese with BMI of 35 kg/m2 or higher
Severe renal insufficiency due to intrinsic renal disease (eGFR < 30 ml/min), without arguments that the renal insufficiency is the result of heart failure or impaired hemodynamics
Malignancy with a poor prognosis (to be determined by the treating oncologist)
Any comorbidity with serious impact on global prognosis
Alcohol or drug abuse
Psychosocial instability (psychologist/psychiatrist advice)
Lack of capacity, lack of therapy compliance, lack of insight into the disease

BWGHF

Advanced heart failure:
LVAD and heart transplantation

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