Training in advanced heart failure and transplant cardiology involves a deep dive into technology often not utilized in general cardiology training. As I began my fellowship this year learning how to provide care for patients with end-stage heart failure leading through heart transplantation, I quickly realized the learning curve would be steep. For patients who benefit from heart transplantation, mechanical circulatory support (MCS) options including left ventricular assist devices, extracorporeal membrane oxygenation and total artificial heart may all be considered as a possible "bridge" to transplantation. Using these devices relies upon an understanding of basic physics, cardiac hemodynamics and hematology. Many patients derive benefit from MCS as either a destination therapy or making it to heart transplantation.

On the post-transplant side, the risk of allograft rejection remains high early after transplant. Tools of surveillance for allograft rejection have evolved beyond basic imaging and endomyocardial biopsy. Tests including intracellular mRNA quantification via polymerase chain reaction, as well as microarray assessment of molecular aspects of biopsies, are utilized in daily practice and being investigated in research to optimize outcomes. They can help individualize care and predict the risk of allograft rejection beyond traditional measures. Moreover, advanced imaging including cardiac computed tomography and cardiac magnetic resonance imaging are being actively investigated to monitor for cardiac allograft vasculopathy and predict risk after heart transplant. These are just some of the tools for the modern heart failure and transplant cardiologist to incorporate in extending quantity and quality of life for patients with heart failure.

When I first rotated to the post-heart transplant inpatient service, our team was providing care for a patient who had received a heart transplant many years prior and was now critically ill. Multiple complications from immunosuppression and gastrointestinal bleeding left him in a debilitated state. Furthermore, attempts at aggressive interventions including MCS or consideration of re-transplant would be aggressive and his previously stated goals regarding quality of life. We quickly arranged for a family meeting with our team and our patient's loved ones. In the small recesses of an intensive care unit conference room, we introduced ourselves and informed our patient's family with an update and expected trajectory. Our team's attending physician explained his long relationship with our patient, emphasizing clinic visits that were recently filled with discussing complications and not visiting grandchildren. After re-visiting a previously written advanced directive, it was clear our patient's goals, values and preferences were not in line with aggressive interventions at this point. Shifting goals to comfort measures was not admitting defeat, but more so understanding when it is appropriate to pull back and let nature take its course. During that conversation, the innovative technologies I was just beginning to digest flew out the door. In fact, basic connections regarding patient values and appropriate use of palliative care became the most important aspect part moving forward. As we wrapped up our meeting, the family thanked us. Fortunately, our patient left the hospital for home hospice to spend time with his family.

The tools allowing us to push the extremes of life are evident while training in advanced heart failure and transplant cardiology. Patients whose mortality was more than 95 percent years ago are being supported mechanically through heart transplantation and living long and meaningful lives years after transplant. However, these tools are not to be used without discretion and reflection. In fact, the patient-care aspect of cardiology has never felt more indispensable as technology advances. Understanding how to balance the use of aggressive interventions while respecting the end of life is a tremendous and rewarding underpinning of advanced heart failure and transplant cardiology training and practice.

This article was authored by Kevin S. Shah, MD, advanced heart failure and transplant cardiology fellow at Cedars-Sinai Heart Institute in Los Angeles, CA. (Twitter: @KevinShahMD)