Timely referrals for transplantation or left ventricular assist device (LVAD) placement, along with incorporation of the patient's preferences and goals of care, may play a key role in favorable outcomes in patients with advanced heart failure, according to a perspective from ACC's Heart Failure and Transplant Council published March 23 in the Journal of the American College of Cardiology.

Maya E. Guglin, MD, PhD, FACC, et al., explain the decision-making process for candidacy for advanced therapies and describe the potential impact of the new organ allocation algorithm on center decision-making. They note that although it is assumed that all cardiologists and most internal medicine physicians recognize that patients with advanced heart failure should be referred to a transplantation or mechanical circulatory support center, referrals are commonly delayed, sometimes beyond the point of candidacy for either intervention.

The authors first address the signs of advanced heart failure, specifically focusing on the importance of the syndrome of low cardiac output as a key feature of advanced heart failure. They note that lacking from all the definitions is the recognition that advanced heart failure requires different treatment strategies and that a key component in many patients with advanced stages of the disease is the decreased forward flow that defines the syndrome of low cardiac output.

Furthermore, the document summarizes the evaluation as a three-step process addressing the following questions: 1) Is transplantation or durable assist device placement indicated?; 2) Are there contraindications to either intervention?; and 3) How can one choose between transplantation and LVAD implantation if advanced therapies are indicated and not contraindicated?

"This review is the first document of this kind since recent changes in the donor organ allocation algorithm," the authors conclude. "How the new allocation process will affect listing practices, management of listed patients and outcomes following heart transplantation remains to be determined."

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support

Keywords: Cardiac Output, Low, Heart-Assist Devices, Heart Transplantation, Heart Failure, Decision Making, Referral and Consultation, Algorithms, Patient Care Planning

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