Patient Selection for Long-Term Mechanical Circulatory Support: Is It Ever too Early for the NYHA Class III Patient?

Heart failure is a common condition with significant morbidity and mortality. Pharmacologic and device therapies have resulted in substantial improvements in heart failure outcomes. Despite optimal therapy, 10 % of patients progress to advanced HF, characterized by progressive symptoms, poor quality of life, and poor prognosis. The “gold-standard” treatment of advanced heart failure remains cardiac transplantation. However, the number of patients with advanced heart failure far exceeds available donor organs. Left ventricular assist devices (LVADs) were initially developed to bridge patients with hemodynamic collapse to transplantation. Their use resulted in marked improvements in survival and quality of life in select patients giving rise to increased and expanded overall implantation. Despite these improvements, patient selection and timing for LVAD therapy is still evolving. In this article, we will review a brief history of LVADs, examine patient selection, and explore the currently debated expansion of LVADs to “less sick” patients.