Assessment and management of heart failure after left ventricular assist device implantation.

A 56-year-old man with a history of ischemic cardiomyopathy and New York Heart Association functional class IV heart failure (HF) requiring intravenous ino-tropic therapy underwent uncomplicated implantation of a continuous-flow left ventricular assist device (LVAD) as bridge to heart transplantation (HT). The patient was weaned off inotropic support during the first week after surgery and had progressive improvement in functional status. He was discharged home on maintenance antithrombotic therapy with aspirin 325 mg once daily and warfarin targeted to an international normalized ratio of 2.0 to 3.0. Eight weeks after LVAD implantation, he developed progressive dyspnea on exertion, recurrent pedal edema, and a 7-pound weight gain. Physical examination revealed conjunctival pallor, a palpable carotid pulse, jugular venous pressure of 14 cm H 2 O, and 2+ pitting edema bilaterally. A rapid and targeted assessment of recurrent HF is essential in this LVAD patient because of multiple , potentially life-threatening causes that necessitate divergent treatments. The US Food and Drug Administration first approved implantable LVADs as a bridge to transplantation in 1994. 1 Although HT remains the gold standard therapy for selected patients with end-stage HF, the stable donor base of <2500 hearts per year in North America limits its widespread applicability. 2 The landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial established the first-generation, pulsatile-flow HeartMate (HM) XVE LVAD as a viable, life-prolonging treatment in patients who were not candidates for HT, a strategy known as destination therapy (DT). However, survival 2 years after implantation was still only 23%, in part because of the high rates of mechanical pump failure. The advent of continuous-flow LVADs has provided a more durable long-term treatment that improves quality of life and survival. 3 The continuous-flow HM II LVAD has a markedly lower rate of device failure (0.06 versus 0.51 events per patient-year) and overall lower complication rates than the pulsatile HM XVE. Furthermore, survival at 2 years was 58% with the HM II compared with 24% with the HM XVE. Continued improvements have come with increasing experience, and 2-year actuarial survival for continuous-flow LVADs is now 70%. 4 This has made DT a viable option for a much larger number of patients and accommodated longer waiting times for bridge-to-transplan-tation patients. Consequently, there has been a significant increase in both the number of LVADs implanted for DT and the use of continuous-flow LVADs, which now account for …