Device Therapy in Refractory Heart Failure

Abstract

Advanced heart failure (HF) has been defined as persistent symptoms that limit daily life despite optical medical therapy, corresponding to New York Heart Association (NYHA) class III/IV symptoms or to the newer classification of stage D HF (ACC/AHA staging classification). It affects 10% of the HF population and is associated with a poor quality of life, recurrent hospitalizations and a mortality approaching 50% at 1 year and 80% at 5 years. Despite the widespread use of angiotensin converting enzyme (ACE) inhibitors, beta adrenergic blocking agents and spironolactone which improve the prognosis in mild to moderate stages, HF remains a progressive disease leading to decompensation and demand of both inotropic agents (class III recommendation according to ACC/AHA guidelines, considered solely for palliation in patients with end-stage disease) and diuretics to treat hypotension, impaired renal function and pulmonary congestion.

Heart transplantation (HT) is associated with nearly 90% 1-year survival, 60% 10-year survival and 95% freedom from symptoms and activity limitations in survivors throughout the follow-up period. Nevertheless, the lack of available donors and the large number of patients, who do not meet the criteria for transplantation, have spurred interest in cardiac resynchronization therapy (CRT) and mechanical circulatory support (MCS), providing alternatives for patients waiting for HT (bridge to transplantation, BTT), patients who are ineligible for HT (destination therapy, DT) or patients who are anticipated to recover after left ventricular unloading (bridge to recovery, BTR)... (excerpt)