4.4 Biventricular failure
Patients with chronic biventricular failure with severe right ventricular failure are not good candidates for LT-MCS with LVAD therapy alone. Biventricular support with 2 blood pumps (implantable or extracorporeal) or implantation of a total artificial heart (TAH) should be considered. However, patients presenting with acute biventricular failure could initially be treated with a biventricular assist device (BiVAD) and may ultimately prove to be candidates for LVAD support only after a period of right ventricle (RV) unloading with a temporary right ventricular assist device (RVAD).
Due to the limitations of any single criterion to predict HF prognosis and MCS postoperative mortality, comprehensive risk assessment by a dedicated advanced HF team is recommended. Numerous single risk markers and composite risk scores have been derived and validated and are available as interactive online tools that can assist the heart team with comprehensive risk assessments and facilitate informed decisions (Supplementary Material, Table S2) [13–16]. However, most of the prognostic tools were derived and validated in clinical trial populations or from single-centre experiences. Therefore, these may not be generalizable to the ‘real-world’ HF population.
Nevertheless, objective risk markers and scores, if deployed as part of a comprehensive assessment by an HF team, are useful for prognostication and prioritization [17]. Clinical history such as recurrent HF hospitalizations and the physician’s gestalt from the patient encounter are critical. Moreover, numerous plasma biomarkers of neurohormonal activation, cardiomyocyte injury or stress, inflammation, fibrosis and multifactorial markers are independent markers of outcome in patients with advanced HF [18]. The cardiopulmonary exercise test provides a set of integrated parameters that represent not only cardiac but also peripheral function. This finding may be particularly helpful in selecting patients who are not inotrope-dependent for LT-MCS therapy, given the fact that impaired exercise tolerance was an inclusion criterion in most LT-MCS studies.
It is crucial to perform a thorough evaluation of the psychosocial situation of potential candidates for LT-MCS. For example, outcomes after LT-MCS implantation are inferior in patients living alone [19]. Active substance abuse is a contraindication to implantation of LT-MCS. Finally, non-patient-related factors, such as organization of care and access to follow-up and treatment, are also strongly associated with outcomes [20].
Despite the availability of an extensive set of prognostic parameters, predicting outcomes both in the absence and presence of advanced HF interventions remains difficult. Furthermore, patients are often referred to specialized advanced HF centres too late. The concept of active screening for advanced intervention has been proposed to improve appropriate referral and treatment in patients with advanced HF [21].