Defining Ambulatory Advanced Heart Failure: MedaMACS and Beyond.

PURPOSE OF REVIEW: Extended survival with LVADs has generated interest in implantation for ambulatory patients with advanced heart failure (HF) prior to dependence on inotropes, though we remain limited in our ability to define and advance indications in this less sick advanced HF population.

RECENT FINDINGS: The MedaMACS and ROADMAP studies have informed prognosis and decision-making for ambulatory patients with advanced HF. Sicker INTERMACS profiles are consistently associated with high risk of death or rescue LVAD. Appropriately selected patients in profile 4 should be considered for LVADs based on their high mortality and poor quality of life. These studies also shed light on discordant perceptions of HF disease severity between patients and their physicians. For ambulatory patients with HF not at imminent risk of death, shared decision-making about LVAD requires measured and individualized consideration of risk and benefit beyond survival. Future studies, including the ongoing REVIVAL study, should provide additional prognostic information in this patient population and should aid patients, caregivers, and physicians as they contemplate complex decisions regarding LVAD therapy.