Refractory heart failure dependent on short-term mechanical circulatory support: what next? Heart transplant or long-term ventricular assist device.

Chronic heart failure is a progressive and eventually fatal illness. Although the disease cannot be cured and treatment is symptom oriented, most of the patients benefit from optimum medical treatment. Patients with rapid deterioration in chronic advanced heart failure refractory to medical treatment need inotropic support and may need intra-aortic balloon pump to maintain circulatory support, which of course cannot be prolonged beyond a certain limit. The outcome of heart transplant and long-term ventricular assist device (VAD) in such patients is poor. The short-term mechanical circulatory support (MCS) offered to such patients not only provides effective circulatory support and stabilizes them hemodynamically, but also halts the ensuing or reverts the established end-organ failure. As the name suggests, the short-term MCS offers support for the short term, usually less than a month. Although some patients with acute heart failure experience recovery of myocardial function with short-term MCS support, others become dependent. These patients, stabilized and "stuck" with short-term MCS, can be "rescued" with long-term VAD or heart transplantation. Both the procedures, when done in this special situation, have their inherent advantages, disadvantages, and complications and hence need the careful consideration about the choice of the procedure. We have tried to elucidate this situation by considering the advantages and disadvantages of both options.