1. Introduction
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Heart failure (HF) affects an estimated 6.5 million people in the United States currently. Optimal medical [1,2] and resynchronization device [3] therapy can lead to reverse myocardial remodeling with symptomatic and survival benefit. However, about 0.5%-5% of patients with HF will progress to end-stage disease [4]. These patients have a poor quality of life with recurrent hospitalizations and a high mortality rate (1-year mortality in ambulatory class III-IV patients is >25% and exceeds 50% in class IV patients) [5,6]. Therapeutic options for these patients include heart transplant or left ventricular assist device (LVAD) therapy, either as a strategy of a bridge to transplantation (BTT) or as destination therapy (DT). Although heart transplant remains the established therapy of choice for these patients, it is limited by organ availability, wait list mortality, and other comorbidities, such as fixed pulmonary vascular resistance [7]. Fortunately, LVADs to support patients with end-stage HF with reduced ejection fraction (HFrEF) have continued to evolve, with improvement in technology, durability and miniaturization. These devices are a life-saving option for advanced HF patients who are either not candidates for a heart transplant or too high-risk to safely wait for a transplant on medical therapy alone. The International Society for Heart and Lung Transplantation (ISHLT) reported that 19.1% of transplant recipients were bridged with a mechanical support device in 2000, and this number increased to 41.0% in 2012 [8]. LVADs can also be a bridge to decision for patients who are not candidates for transplant at the time of implantation but may become suitable candidates after the procedure [9] and may also be utilized to promote myocardial recovery in a bridge to recovery strategy. Outcomes post-LVAD implantation have continued to improve, with 1-month survival estimates at 96%, and 1- and 2-year survival estimates at 83% and 73%, respectively [10].
Over the past decade, the use of LVADs has increased significantly. In the United States, approximately 421 isolated LVAD implants were performed in 2008. A total of 2118 LVADs were implanted in 2017, which is a significant increase from only 459 implants in 2008. There was a steady increase in the number of LVADs implanted from 2008 to 2015, peaking at 2754 devices annually. Since 2016, the INTERMACS Database reported a decline in annual LVAD volume, related in part to a number of patients who received non-FDA-approved pumps as part of the MOMENTUM 3 clinical trial or a delay in enrollment of patients during contractual negotiations in 2017 between STS and participating hospitals [10]. So far, more than 19,000 patients have received a continuous-flow LVAD in the United States [10]. Thus, there is an increasing need for care of these patients by non-LVAD specialists, such as providers in the emergency department, urgent care centers, outpatient clinics, etc. These encounters may be for LVAD-related or unrelated issues. However, there is limited literature to assist non-LVAD specialists in caring for these complex patients. The aim of this state-of-the-art review, targeting internists and general cardiologists, is to describe the current status of durable LVAD therapy in adults, patient selection, management strategies, complications and to summarize current outcome data.
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