To ventricular assist devices or not: When is implantation of a ventricular assist device appropriate in advanced ambulatory heart failure?

Figure 1 Factors determining timing of left ventricular assist devices implantation. Factors for earlier implantation of left ventricular assist devices are increased survival and quality of life, avoidance of multi-organ deterioration and chronic low cardiac output while factors against earlier implantation are device-related events, surgical risks, and rehabilitation from surgery.

Figure 2 New York Heart Association classes considered for left ventricular assist devices implantation. Currently, FDA approval for LVAD implantation exists for NYHA Class IIIB and IV, which encompasses all of the INERMACS profile levels. ROADMAP is evaluating LVAD implantation in patients of NYHA class III and class IV (ambulatory), which has limited adoption in most clinical practices. MedaMACS looked at the same patient population as ROADMAP however focused on those patients without LVADs. REVIVE-IT was evaluating implantation in patients in NYHA class III, which is not currently FDA approved. LVAD: Left ventricular assist devices; FDA: Food and Drug Administration; MedaMACS: Medical Arm of the Interagency Registry for Mechanically Assisted Circulatory Support; NYHA: New York Heart Association.

Figure 3 Comparison of baseline and 12-mo after enrollment from the ROADMAP study comparing left ventricular assist device implantation with optimal medical management. OMM: Optimal medical management; LVAD: Left ventricular assist device; I-IV: New York Heart Association classification[5] (Reprinted with permission from J Am Coll Cardiol).