Electrical and mechanical support in advanced heart failure. Rationale and feasibility of a combined management strategy

Treatment for congestive heart failure has improved markedly in recent years, particularly with the introduction of newer pharmacological regimens. However, in patients with severely depressed left ventricular dysfunction caused by different aetiologies, prognosis still remains poor despite best medical management. Heart transplantation is an accepted therapeutic option for the management of patients with end-stage heart failure, but a growing number of these patients who are on the waiting list for heart transplantation die due to a shortage of suitable donor grafts. The worsening supply–demand imbalance over the years has stimulated a search for alternative means of ‘bridge to transplantation’. Given the fact that about one-third of all deaths occur suddenly, use of implantable cardioverter defibrillators (ICDs) were considered in the management of these patients. However, there is considerable concern that death from terminal pump failure may nullify the survival benefit conferred by an ICD. On the other hand, arrhythmic death may occur in patients with mechanical pumps, which may justify the strategy of using combined electrical and mechanical support as a bridge to transplantation. In this review, we discuss the rationale and feasibility of this combined clinical management strategy.