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The Art of Decision Making in Patient Selection for Durable MCS: Goldilocks

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Manreet Kanwar, MD
City, State, Country

With an ever increasing use of durable LVADs in end stage heart failure, the need for appropriate patient selection has never been more critical. The determination of who is an 'ideal' candidate remains challenging, given the complexity and multi-dimensional nature of this disease. There are various factors that go into this determination - those related to the disease and its impact on various aspects of the patient's health, their nutritional, financial and psycho-social status, input from caregivers and ability of their health care team to assess and prioritize these issues. As a result, heart failure physicians are constantly debating the need and timing for durable VADs - with both a VAD done 'too soon' or 'too late' in the course of disease presenting their unique downfalls.

There has been much written about risk stratification and outcome prediction in this area. There are multiple tools published for predicting the risk of mortality, right ventricular failure, stroke etc. post VAD but their clinical utilization in real life is limited. This is partly because they have been derived from limited patient numbers, focusing on few clinical parameters. Their major setback is that they try to find linear and non-dynamic correlation between a risk factor and outcome - whereas patients requiring MCS support are far too complex for these conclusions. A risk score that predicts that an elderly patient on a ventilator, requiring dialysis and pressor support will have a poor outcome post VAD is hardly enlightening. In the absence of validated, dynamic risk prediction algorithms derived from long term, multi-center experiences, physicians continue to use their clinical gestalt while making candidacy decisions.

Another aspect of defining candidacy is the expanding use of MCS from temporary or bridge support to durable/ long term support. Boundaries for patient consideration for both BTT and DT indications are being stretched and redefined. Once considered a fairly absolute contraindication, an increasing number of patients are being maintained on renal replacement therapies while on VAD support. Another example is the increasing number of octogenarians being considered for destination LVADs. Regional and institution specific factors add yet another facet to this decision making. Increasing numbers of young heart failure patients with high BMI and blood group O are receiving a more 'elective' LVAD as BTT under the hope and premise that they will lose enough weight to become eligible for cardiac transplantation.

Health care teams try to fulfill these varying demands by extending the team of people involved in decision beyond heart failure cardiologists and surgeons to include social and financial case workers, psychiatrists, palliative care specialists, care coordinators, administrators and caregivers - with the patient in the center of this whirlwind of decision. Increasing emphasis is being placed on informed decision making with focus on trying to get the patient to have a reasonable idea of what to expect. Some programs set up 'meet and greets' for those considering a VAD where they mingle with patients supported by pumps. Various websites are dedicated to learning about the VADs in layman terms. Yet the gap between the information considered delivered to a patient and what they grasp stays wide. The questions still remain - Do these patients really understand what they are signing up for? Do their caregivers grasp the immensity of their role in the long term? Are we putting enough emphasis on quality of life? Probably equally critical, are we putting enough emphasis on quality of dying?

Good decisions come from experience, and experience comes from bad decisions. (Anonymous) ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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