Heart Failure (HF) is a complex clinical syndrome marked by the heart's inability to pump blood efficiently to meet the requirements of metabolizing tissues or doing so only at an elevated diastolic filling pressure. This condition may arise due to abnormalities in cardiac function, which might be detectable or not, and can occur even under conditions of near-normal cardiac function when there is high demand on the heart. Notably, HF invariably leads to circulatory failure.
Globally, HF affects approximately 26 million individuals, with a higher prevalence in older adults, and is the number one cause of hospitalization. The lifetime risk of developing HF is 1 in 5, and the condition is associated with poor quality of life and survival, with 45-60% of patients dying within 5 years of diagnosis. Additionally, more than 50% of HF patients are rehospitalized within 6 months after discharge. This chronic, progressive condition characterized by symptoms like fatigue, shortness of breath, and fluid retention significantly impacts patient quality of life and increases mortality risk.
In industrialized countries, ischemic cardiomyopathy is the most common cause of HF, while in developing nations, the increase in HF rates is associated with more urbanized and affluent lifestyles, leading to higher rates of diabetes and hypertension. In the United States, HF affects approximately 6.5 million individuals aged 20 years and older. This prevalence is projected to increase by 46% from 2012 to 2030, resulting in over 8 million Americans aged 18 and older suffering from this condition. Annually, about 960000 new cases are diagnosed, with the incidence in individuals over 65 being 21 per 1000 population. The prevalence of HF increases with age, being 1-2% in those younger than 55 years and rising to 10% in those older than 75 years. HF is not limited to the elderly; it can occur at any age, depending on the cause.
The progression of HF involves a network of compensatory mechanisms at various levels, from subcellular to organ-to-organ interactions. These mechanisms initially help maintain heart function by increasing blood volume, cardiac filling pressure, heart rate, and cardiac muscle mass.
However, over time, there’s a progressive decline in the heart’s ability to contract and relax, exacerbating HF. These processes collectively result in increased myocardial energy expenditure, decreased cardiac output, myocardial cell death, and the progression of HF. This complex interplay of factors illustrates the multifactorial nature of HF, involving a cascade of physiological changes that ultimately exacerbate the condition.
The management of HF is complex and requires the integration of pharmacological treatments, lifestyle changes, and, when necessary, surgical procedures, in line with the 2022 AHA/ACC/HFSA Guidelines. Medications such as ACE inhibitors, beta-blockers, SGLT2 inhibitors, and diuretics are used to alleviate symptoms and slow disease progression. Surgical options, like coronary artery bypass grafting and valve replacement, are indicated in the presence of structural cardiac abnormalities contributing to HF. Patients in advanced HF stages, particularly those classified as NYHA class IV or ACC/AHA stage D, exhibit a significantly elevated mortality risk, often exceeding 50%. In these severe cases, conventional therapeutic approaches are frequently inadequate or insufficient. Hence, heart transplantation represents a life-saving option for eligible individuals with end-stage HF. However, transplant candidacy is limited, and the availability of donor hearts remains a challenge.
Ventricular assist devices (VADs), commonly known as artificial hearts, play a crucial role in the management of advanced HF, serving as vital support systems for both acute and chronic decompensated heart conditions, notably in ACC/AHA stage D HF. These devices, including left ventricular assist devices (LVADs), right ventricular assist devices (RVADs), and biventricular assist devices (BiVADs), are designed to augment the function of failing ventricles. They operate by drawing blood from the affected ventricle and channeling it through a pump that delivers it to the major circulatory arteries – the aorta for LVADs and the pulmonary artery for RVADs.
LVADs represent a significant advancement in the treatment of severe HF, particularly benefiting patients ineligible for or awaiting heart transplantation. They offer versatility, serving temporarily as a bridge to recovery in acute severe myocarditis or as a bridge to transplantation in end-stage HF. This approach facilitates necessary rehabilitation and potential return home pre-transplantation. For patients ineligible for transplantation, long-term LVAD use, termed destination therapy, emerges as a viable option, notably improving both the quantity and quality of life. Evidence from trials such as the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive HF (REMATCH) and subsequent studies support the efficacy of LVADs.
Despite their benefits, VADs are associated with potential complications like mechanical breakdown, infection, bleeding, and thromboembolic events. However, the survival rate of approximately 70% for patients receiving VADs is noteworthy, considering the severity of illness in these patients. The ongoing evolution of VAD technology continues to raise important clinical and physiological questions, driving advancements in the field of HF treatment.
Since 2014, the Cardiovascular Institute of Hospital Internacional de Colombia (HIC) has achieved significant progress in the implementation of VADs, having implanted more than 30 of such devices in both national and international patients, including patients from countries such as Ukraine, the Dominican Republic, Panama, China, and pediatric patients. These accomplishments are part of a larger picture of cardiovascular care at the institute, where over the past two years, more than 1700 cardiovascular surgeries have been performed on adult and pediatric patients.
HIC's achievements in cardiac care include its Centers of Excellence, accredited by the Joint Commission International (JCI) for heart failure (HF) and ventricular assist device (VAD) care. Regarding VAD performance, HIC's clinical outcomes demonstrate excellence and safety in patient care. HIC has achieved notable survival rates following the implantation of long-term assist devices. The survival rate for HF patients is 97.60%, surpassing the target set by IQI 2023. For patients undergoing long-term VADs implants, the one-month survival rate is 100%, exceeding the 95% goal according to IMACS standards. Furthermore, the one-year survival rate for patients with long-term VADs stands at 89.3%, surpassing the IMACS benchmark of 80%. These statistics underscore HIC's dedication to advanced cardiac care and highlight their significant contribution to improving life expectancy and quality of life for patients with severe cardiac conditions, establishing HIC as a leader in cardiac treatment and innovation.
