Ann Thorac Cardiovasc Surg 2016; 22: 271–274
Editorial
Online June 27, 2016 doi: 10.5761/atcs.ed.16-00119
Indication of Ventricular Assist Device Therapy in Patients with INTERMACS Profile 4–7 Teruhiko Imamura, MD, PhD1 and Koichiro Kinugawa, MD, PhD2
Optimal timing of ventricular assist device (VAD) therapy has been discussed mainly among patients with heart failure dependent on inotrope infusion, but little is known about the indication of VAD therapy among less sick ambulatory patients. Considering recent improvement of VAD therapy outcome, now is the best time to discuss the expansion of VAD indication into less sick population. In this review, we will investigate optimal candidates for VAD therapy especially among ambulatory populations on the basis of recent evidence. Keywords: heart transplantation, intermacs, cardiopulmonary exercise
Introduction An ultimate solution for the patients with advanced heart failure (HF) is heart transplantation (HTx),1) but the critical limitation of this therapy is a severe shortage of donor hearts. Patients cannot wait HTx for several years without ventricular assist device (VAD) therapy as a bridge to transplant (BTT) strategy. Destination therapy (DT), an indefinite VAD therapy not targeting HTx, is not reimbursed in Japan thus far, and BTT is virtually an only strategy to undergo VAD implantation.2) Advanced HF is minutely categorized into seven profiles by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS).3) Ambulatory patients are assigned to profile 4–7, whereas those dependent on inotrope infusion are assigned to profile 1–3. Prognosis during VAD therapy is largely dependent on patient background condition, and an indication of VAD Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan 2Second Department of Internal Medicine, University of Toyama, Toyama, Toyama, Japan 1
Received: May 17, 2016; Accepted: May 30, 2016 Corresponding author: Koichiro Kinugawa, MD, PhD. Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama 930-0194, Japan Email: [email protected] ©2016 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
Ann Thorac Cardiovasc Surg Vol. 22, No. 5 (2016)
implantation has mainly been discussed among patients with INTERMACS profile 1–3. Various risk factors have been proposed, and optimal patient selection strategy is now being established among these populations. Recently, ROADMAP study, a prospective multicenter observational study, showed that survival rate as well as functional status was better with VAD therapy compared with optimal medical therapy among those with INTERMACS profile 4–5.4) However, not all patients with INTERMACS profile 4–7 are good candidates for VAD therapy, and optimal patients’ selection among these populations is desired. In this review, we will discuss the indication of VAD therapy especially in patients with INTERMACS profile 4–7. Optimal patient selection in patients with INTERMACS profile 4–7 We have to consider risk and benefit among patients with INTERMACS profile 4–7 when VAD therapy is about to be indicated especially considering various complications by VAD treatment. So far, there have been few criteria for optimal patients’ selection among these populations. We traditionally use cardiopulmonary exercise (CPX) test to consider VAD indication in ambulatory populations. Indication using cardiopulmonary exercise data The conventional indication of VAD therapy is peak oxygen consumption (PVO2) below 14 or 10 mL/min/kg. 271
Imamura T and Kinugawa K
This parameter is simple but proposed in the era when neither β-blocker nor angiotensin converting enzyme inhibitor was used as standard therapy. Aaronson et al. previously proposed HF survival score (HFSS), which consisted of seven clinical variables including PVO2 to select HTx candidates. Goda et al. demonstrated an advantage of HFSS over PVO2 alone for the risk stratification of HF patients. We also proposed a novel scoring system to predict future VAD implantation by using 4 simple CPX parameters including PVO2 (CPX score).5) In this scoring system, VE/VCO2 slop >44.3, peak hear rate
Editorial
Online June 27, 2016 doi: 10.5761/atcs.ed.16-00119
Indication of Ventricular Assist Device Therapy in Patients with INTERMACS Profile 4–7 Teruhiko Imamura, MD, PhD1 and Koichiro Kinugawa, MD, PhD2
Optimal timing of ventricular assist device (VAD) therapy has been discussed mainly among patients with heart failure dependent on inotrope infusion, but little is known about the indication of VAD therapy among less sick ambulatory patients. Considering recent improvement of VAD therapy outcome, now is the best time to discuss the expansion of VAD indication into less sick population. In this review, we will investigate optimal candidates for VAD therapy especially among ambulatory populations on the basis of recent evidence. Keywords: heart transplantation, intermacs, cardiopulmonary exercise
Introduction An ultimate solution for the patients with advanced heart failure (HF) is heart transplantation (HTx),1) but the critical limitation of this therapy is a severe shortage of donor hearts. Patients cannot wait HTx for several years without ventricular assist device (VAD) therapy as a bridge to transplant (BTT) strategy. Destination therapy (DT), an indefinite VAD therapy not targeting HTx, is not reimbursed in Japan thus far, and BTT is virtually an only strategy to undergo VAD implantation.2) Advanced HF is minutely categorized into seven profiles by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS).3) Ambulatory patients are assigned to profile 4–7, whereas those dependent on inotrope infusion are assigned to profile 1–3. Prognosis during VAD therapy is largely dependent on patient background condition, and an indication of VAD Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan 2Second Department of Internal Medicine, University of Toyama, Toyama, Toyama, Japan 1
Received: May 17, 2016; Accepted: May 30, 2016 Corresponding author: Koichiro Kinugawa, MD, PhD. Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama 930-0194, Japan Email: [email protected] ©2016 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
Ann Thorac Cardiovasc Surg Vol. 22, No. 5 (2016)
implantation has mainly been discussed among patients with INTERMACS profile 1–3. Various risk factors have been proposed, and optimal patient selection strategy is now being established among these populations. Recently, ROADMAP study, a prospective multicenter observational study, showed that survival rate as well as functional status was better with VAD therapy compared with optimal medical therapy among those with INTERMACS profile 4–5.4) However, not all patients with INTERMACS profile 4–7 are good candidates for VAD therapy, and optimal patients’ selection among these populations is desired. In this review, we will discuss the indication of VAD therapy especially in patients with INTERMACS profile 4–7. Optimal patient selection in patients with INTERMACS profile 4–7 We have to consider risk and benefit among patients with INTERMACS profile 4–7 when VAD therapy is about to be indicated especially considering various complications by VAD treatment. So far, there have been few criteria for optimal patients’ selection among these populations. We traditionally use cardiopulmonary exercise (CPX) test to consider VAD indication in ambulatory populations. Indication using cardiopulmonary exercise data The conventional indication of VAD therapy is peak oxygen consumption (PVO2) below 14 or 10 mL/min/kg. 271
Imamura T and Kinugawa K
This parameter is simple but proposed in the era when neither β-blocker nor angiotensin converting enzyme inhibitor was used as standard therapy. Aaronson et al. previously proposed HF survival score (HFSS), which consisted of seven clinical variables including PVO2 to select HTx candidates. Goda et al. demonstrated an advantage of HFSS over PVO2 alone for the risk stratification of HF patients. We also proposed a novel scoring system to predict future VAD implantation by using 4 simple CPX parameters including PVO2 (CPX score).5) In this scoring system, VE/VCO2 slop >44.3, peak hear rate
