The role of mechanical circulatory support in advanced heart failure: Indications and patient selection

The population of heart failure patients and the mortality attributed to this disease continues to grow despite reductions in mortality from all other cardiovascular diseases. This trend has been attributed to improvements in the management of various cardiac diseases including acute ischemic heart disease and chronic left ventricular dysfunction. It is estimated that nearly 5 million Americans have heart failure and that 5% of those have reached the most advanced symptomatic stages. This is a very visible population as a result of the severity of lifestyle limitations, the frequency of hospitalizations, and the high mortality rate. Although it is clear that medical therapy directed at neurohormonal inhibition improves symptoms and reduces the morbidity and mortality associated with this disease, the benefits are more limited in those with advanced heart failure. There has been a great deal of progress in the utilization of mechanical circulatory support in the past three decades. Devices have become more reliable and are associated with fewer complications than in past eras. Experience with short- and intermediate-term circulatory support has expanded consideration of this technology to additional populations who may derive benefit. Currently accepted indications and contraindications for mechanical circulatory support as well as factors that increase the risk for morbidity and mortality are reviewed.