title: Outcome of conservative management vs. assist device implantation in patients with advanced refractory heart failure.
abstract: BACKGROUND
  In patients with advanced refractory heart failure (HF) cardiac transplantation (HTX), conservative medical management and the implantation of a ventricular assist device (VAD) represent valuable options. The determination of the best therapeutic destination strategy for the individual patient remains a challenge. The aim of this study was to assess the clinical outcome in advanced refractory HF patients either managed conservatively receiving optimal contemporary medical therapy ('conservative'), or who who underwent pulsatile flow VAD ('pVAD') or continuous-flow VAD ('contVAD') implantation.
  
  
  METHODS
  A total of 118 patients with INTERMACS profile >1 at baseline, who died, or fully completed a 24-month follow-up free from HTX were included into this retrospective analysis. All-cause mortality at 24 months was assessed and compared between the three groups.
  
  
  RESULTS
  Fifty (42%) patients were managed conservatively, 25 (21%) received a pVAD and 43 (36%) a contVAD. NT-proBNP values were comparable between the three groups (median 4402 (IQR 2730-13390) pg/mL, 3580 (1602-6312) pg/mL and 3693 (2679-8065) pg/mL, P = 0·256). Mean survival was 18·6 (95% CI 16·2-21·0) months for patients managed conservatively, 7·0 (3·9-10·0) for pVAD and 20·5 (18·2-22·8) for contVAD (overall log-rank test P < 0·001). Conservatively managed patients spent a mean of 22·4 (95% CI 22·1-22·8), pVAD 17·7 (15·4-20·1) and contVAD 21·6 (21·2-22·1) months out of hospital (conservative vs. pVAD P < 0·001; conservative vs. contVAD P = 0·015; pVAD vs. contVAD P < 0·001).
  
  
  CONCLUSIONS
  In accordance with the literature, contVAD resulted in a significantly better clinical outcome than pVAD implantation. However, conservative management with current optimal medical therapy appears to remain a valuable option for patients with advanced HF.
authors.affiliation: Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria.|4th Medical Department, Hietzing Hospital, Medical University of Vienna, Vienna, Austria.
authors.forename: Christopher
authors.initials: C
authors.lastname: Adlbrecht
authors.affiliation: Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria.
authors.forename: Martin
authors.initials: M
authors.lastname: Hülsmann
authors.affiliation: Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria.
authors.forename: Raphael
authors.identifier: http://orcid.org/0000-0003-3027-7775
authors.initials: R
authors.lastname: Wurm
authors.affiliation: Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
authors.forename: Farsad
authors.initials: F
authors.lastname: Eskandary
authors.affiliation: Division of Cardio-Thoracic-Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Medical University of Vienna, Vienna, Austria.|Division of Infectiology and Tropical Medicine, Department of Internal Medicine IV, KFJ Social-Medical Center South, Medical University of Vienna, Vienna, Austria.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Neuhold
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Andreas
authors.initials: A
authors.lastname: Zuckermann
authors.affiliation: Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria.
authors.forename: Andja
authors.initials: A
authors.lastname: Bojic
authors.affiliation: Complexity-Research, Research Institute for Complex Systems, Vienna, Austria.
authors.forename: Guido
authors.initials: G
authors.lastname: Strunk
authors.affiliation: Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria.
authors.forename: Richard
authors.initials: R
authors.lastname: Pacher
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D005260:Female; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy*; D006353:Heart-Assist Devices; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D000451:Mineralocorticoid Receptor Antagonists / Q000627:therapeutic use*; D012189:Retrospective Studies; D013318:Stroke Volume / Q000502:physiology; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D000451:Mineralocorticoid Receptor Antagonists
keywords: Conservative management; heart failure; ventricular assist device