Ventricular Assist Devices for Durable Support
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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 noninsulin-dependent 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.
Beyond Standard Therapy
This patient has recurrent heart failure despite having received the standard therapies known to improve outcome and clinical status.1 Renal dysfunction would preclude cardiac transplantation, which, in the setting of limited donor availability, would not often be offered to patients in this age group with major comorbidities. In patients with comprehensive home support, chronic inotropic infusion might be considered for palliation of end-stage symptoms, understanding that death is imminent and may be accelerated by inotropic therapy. For most patients with refractory “stage D” heart failure,2 the focus should shift toward comfort and planning with patient and family (Figure 1).