11 Success with MCS – starting from patient selection. (9th April 2018) - Lahpor, Jakob R
Abstract : Since the introduction of continuous flow (CF-)VADs a decade ago, 1 early and mid-term survival rates have dramatically improved with 1 year survival of 85% or higher. 2 3 These better survival rates should not only be attributed to improvement in technology and patient management but also to better patient selection and better timing of implantation. 1 From the REMATCH study (2001) with the pulsatile HeartMate 1 LVAS we learned that the high 6 month mortality of 40% was mainly a result of poor selection of patients. Since the introduction of CF-VADs in 2008, the INTERMACS registry has shown a significant reduction in INTERMACS Profile 1 ('crashing and burning') VAD patients at the time of implantation, resulting in 6 month survival rates of 90% or higher. Also, the HeartMate II ROADMAP Study has shown that earlier implantation in less sick non-hospitalised patients results in statistically better survival. 4 During the last decade, introduction of individual patient risk profiles such as the Lietz-Miller score, Michigan Score (Matthews, 2008) and the HeartMate II risk score has attributed to improved patient selection. 2 In this regard in many publications the importance of pre-implant assessment by ultrasound or haemodynamic metrics of the right ventricular function and its pre- and afterload (i.e. pulmonary vascular resistance or PVR) has been stressed to optimise the patient obtaining a better result of VAD implantation. 5 This has resulted in many other risk stratifications such as the EuroMACS Right-Sided Heart Failure Risk or the TTE score (Raina, 2013). References: . Rose EA, et al . Long-term use of left ventricular assist device for end-stage heart failure. NEJM 2001;345:1435–43. . Lietz K, et al. Outcomes of left ventricular assist device implantation in the post-rematch era: Implications for patient selection. Circulation2007;116(5):497–506. . Kirklin JK, et al. 5th and 6th annual INTERMACS reports. J Heart Lung Transplant 2014–2015. . Estep JD, et al. Risk assessment and comparitive effectiveness of left ventricular assist devices and medical management in ambulatory heart failure patients: Results from the ROADMAP study. J Am Coll Cardiol2015;66(16):1747–61. . Soliman O, et al. Derivation and validation of a novel right-sided heart failure model after implantation of continuous flow left ventricular assist devices. Circulation2017;136.