Evaluation for a ventricular assist device: selecting the appropriate candidate.

Case presentation: A 57-year-old woman with ischemic and valvular heart disease presents with progressive heart failure while awaiting cardiac transplantation. Several years ago, after a large anterior myocardial infarction, she underwent 4-vessel CABG. Her subsequent course was complicated by atrial fibrillation and then recurrent heart failure. She also developed progressive aortic stenosis and mitral and tricuspid regurgitation and underwent aortic valve replacement with a 17-mm St. Jude valve, as well as mitral and tricuspid valvuloplasty. Two years later, she developed worsening symptoms of heart failure. She continued to fail despite escalating medical therapy and was listed for cardiac transplantation 6 months before this hospitalization. She is now admitted with severe heart failure and has been stabilized on intravenous positive inotropic therapy. She is 5 feet 2 inches tall, weighs 104 pounds, and has a body surface area of 1.4 m2. What are the best options to manage her as she awaits transplantation: Continued parenteral inotropic support, a ventricular assist device (VAD), or both as a bridge to transplantation? Heart failure is the final pathway of a progressive disease that can originate from a variety of cardiovascular processes. Improved acute medical care and prevention of sudden cardiac death have led to an increased prevalence of advanced heart failure. The prognosis of heart failure is dismal, with 50% of patients dead within 4 years, a percentage that matches that of many common malignancies.1 Of those hospitalized with an acute exacerbation, the mortality rate within 1 year has been reported to be between 30% and 50%.2,3 Numerous factors in clinical studies consistently have been identified to be associated with poor prognosis: Advanced age, decreased blood pressure, reduced ejection fraction, chronic kidney disease, diabetes mellitus, anemia, hyponatremia, and persistently high levels of natriuretic peptides. Yet, no single clinical variable or …