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Navigating the Evolving Landscape of Durable Mechanical Circulatory Support: Insights on Patient Selection, Outcomes, and Future Advancements

Core Concepts
The field of durable mechanical circulatory support (MCS) is navigating a complex landscape, balancing the benefits and challenges of device advancements, patient selection, and the impact of policy changes on access to heart transplantation.
The discussion covers the key aspects of durable MCS, particularly left ventricular assist devices (LVADs): The impact of the 2018 change in the heart transplant allocation system, which has led to a dramatic increase in the use of temporary MCS and a decrease in durable MCS. This has resulted in both positive and negative consequences, including increased hospital lengths of stay and concerns about "double jeopardy" for LVAD patients. The importance of a patient-centric approach to LVAD selection, considering factors such as age, cardiac and non-cardiac comorbidities, and the patient's goals and preferences. Clinicians must carefully weigh the potential benefits of LVADs in terms of total life-years against the risks of complications. The evolving process of shared decision-making with patients, where clinicians provide comprehensive information about LVAD and transplant options, allowing patients to make informed choices over multiple sessions. The ongoing advancements in LVAD technology, with the goal of creating a "forgettable" device that is fully implantable, reduces the risk of complications, and enables earlier referrals and broader acceptance by both patients and referring providers. The need for a collaborative, field-wide approach to improve outcomes and continue the progress in durable MCS, rather than a solely patient-centric or center-centric perspective.
One year after heart transplant in the US, survival is 92%. One year after LVAD transplant, for a young patient, survival is 92%.
"If you have a young patient who's in her 30s and he or she has children, they are thinking about total life-years. One thing that I will counsel them on is total life-years, meaning if you're a low-risk VAD case and have low risk for anticipated complications, can we add your anticipated survival on VAD support to your anticipated survival after transplant for total life-years?" "We're going to ask a patient to picture themselves living on an artificial heart pump that they've never heard of or seen; they really don't know what life will be like afterward, and they think, gosh, I'll never be able to shower. Yet we know that there's this thing called response shift that occurs, where once they're living on an LVAD, they're like, 'I was so worried about not being able to shower. But just the fact that I can go to my granddaughter's volleyball game, showering is no big deal.'"

Key Insights Distilled From

by Michelle M. ... at 05-16-2024
S2 Episode 6: Insights Into Durable Mechanical Circulatory Support

Deeper Inquiries

How can clinicians better incorporate patient preferences and values into the decision-making process for durable MCS, beyond just clinical factors?

Incorporating patient preferences and values into the decision-making process for durable MCS goes beyond just clinical factors and requires a patient-centered approach. Clinicians can achieve this by engaging in shared decision-making with patients, where the patient's values, goals, and preferences are considered alongside clinical data. This involves open communication, active listening, and providing information in a way that is easily understandable to the patient. Clinicians should take the time to discuss the potential benefits and risks of durable MCS, including the impact on quality of life, daily activities, and long-term outcomes. Understanding what matters most to the patient, whether it's spending time with family, maintaining independence, or pursuing certain activities, can help tailor the treatment plan to align with their values. Additionally, involving patients in the decision-making process empowers them to make informed choices about their care. This can be achieved through educational materials, decision aids, and discussions that explore the patient's preferences regarding treatment options, potential outcomes, and expectations. By considering the patient's values and preferences alongside clinical factors, clinicians can ensure that the treatment plan is personalized and aligned with the patient's goals.

What are the potential unintended consequences of the pendulum swinging too far in the direction of prioritizing direct heart transplantation over durable MCS, and how can the field find a balanced approach?

The pendulum swinging too far in the direction of prioritizing direct heart transplantation over durable MCS can have several unintended consequences. One major consequence is the potential exclusion of patients who may benefit from durable MCS but are not considered high-priority candidates for transplantation. This could lead to delays in receiving life-saving treatment, increased hospital stays, and higher healthcare costs. Another consequence is the increased burden on transplant centers, as more patients are listed for direct transplantation without utilizing durable MCS as a bridge to transplant. This can strain resources, impact waitlist times, and potentially compromise outcomes for patients who could have benefited from MCS support before transplantation. To find a balanced approach, the field of advanced heart failure therapy needs to consider individualized patient care, weighing the benefits and risks of both durable MCS and transplantation for each patient. This involves comprehensive patient evaluation, shared decision-making, and a multidisciplinary team approach to determine the most appropriate treatment strategy. Clinicians should aim to optimize patient outcomes by selecting the most suitable treatment option based on the patient's clinical profile, preferences, and values. By striking a balance between durable MCS and transplantation, the field can ensure equitable access to life-saving therapies while maximizing patient outcomes and resource utilization.

What technological advancements in areas such as energy delivery, infection control, and device miniaturization are needed to truly create a "forgettable" durable MCS device, and what is the timeline for these innovations to reach clinical practice?

Creating a "forgettable" durable MCS device requires advancements in several key areas, including energy delivery, infection control, and device miniaturization. Energy Delivery: Developing more efficient and reliable energy delivery systems for durable MCS devices is crucial to reduce the risk of driveline-related complications and improve patient comfort. Transcutaneous energy transfer systems that eliminate the need for external power sources or drivelines are being explored to enhance patient mobility and quality of life. Infection Control: Improving infection control measures, such as the use of antimicrobial coatings, sterile techniques during device implantation, and remote monitoring for early detection of infections, is essential to minimize the risk of device-related infections. Advancements in materials science and infection prevention strategies can help enhance the safety and longevity of durable MCS devices. Device Miniaturization: Miniaturizing durable MCS devices to make them less obtrusive and more easily implantable is a key goal for creating a "forgettable" device. Smaller, more compact designs that are fully implantable and reduce the need for external components can improve patient comfort and reduce the risk of device-related complications. The timeline for these innovations to reach clinical practice may vary, as research and development in these areas are ongoing. While some advancements, such as improved infection control measures, may be implemented in the near future, achieving a fully implantable, forgettable durable MCS device may take several years of continued research, testing, and regulatory approval. Collaboration between clinicians, engineers, and industry partners is essential to drive innovation and bring these technological advancements to the forefront of advanced heart failure therapy.