ABSTRACT
The progress in medical therapy for heart failure has allowed many patients to remain stable
with adequate resting perfusion and good quality of life despite low left ventricular ejection
fraction. Systematic, serial adjustment of recommended medications and, in some cases,
pacing devices is required before patients can be considered to have moved “beyond medical
therapy”(1). At this stage, some patients are evaluated for definitive options such as cardiac
transplantation and/or mechanical cardiac support devices, while the majority should partner
in decisions regarding end-of-life care. The selection of patients for implantable ventricular
assist devices, as with any therapy, centers on the expected improvement of outcome offered
by the intervention (2). Currently, there are only a small number of patients for whom benefit
is anticipated from left ventricular assist devices, but relatively minor improvements
in current device outcomes could dramatically increase the candidate population. While
the majority of left ventricular assist devices are implanted with intent for a bridge to
transplantation, many transplant candidates now survive beyond 6 mo and sometimes 1-2 yr
on VAD before transplantation, which for some patients may never occur. The boundary
between devices for bridge and for permanent “destination” is increasingly blurred, both for
the initial selection decision and for the collection of outcomes. This chapter will focus on
selection of patients for “destination” VAD, but it may soon be most appropriate to consider
for “durable” VAD support, without pre-specification of ultimate transplant status.
