Ventricular assist devices for durable support.

Clinical Challenge What can we offer a 70-year-old retired schoolteacher hospitalized with congestion for the third time in 6 months? The LVEF is 21%. Shortness of breath interrupts sleeping and dressing, and peak oxygen consumption of 9 mL/kg per minute confirms NYHA Class IV status. He has noninsulindependent diabetes and chronic coronary artery disease, with patent grafts to thin-caliber vessels. His systolic blood pressure is 88 mm Hg and jugular venous pressure of 15 cm. Angiotensin-converting enzyme inhibitor (ACEI) and spironolactone were stopped during his last hospitalization because of progressive increase in serum creatinine to 3.8 mg/dL, currently 2.7, estimated clearance of 25 cc/min, and proteinuria. His regimen includes low doses of hydralazine and isosorbide dinitrate and digoxin, and he cannot tolerate beta-blockers. Although he is followed in an advanced heart failure management program, fluid retention has recurred despite torsemide 200 mg twice daily, intermittent metolazone, and compliance with 2-L fluid restriction, 2-g sodium diet, and daily weights. Serum sodium is 135 mEq/L, and B-type natriuretic protein (BNP) level is 1822 pg/mL. He expresses a willingness to try anything to feel better.