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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e959 CLINICAL STATEMENTS AND GUIDELINES

pump mechanisms, and ventricle(s) supported. It can be effective for short-term support (hours to days) and for longterm management (months to years). There are anatomic and physiologic criteria that make durable MCS inappropriate for some patients; it is most appropriate for those with HFrEF and a dilated ventricle. With any form of MCS, the device will eventually be turned off, whether at the time of explant for transplantation or recovery, or to stop support in a patient who either no longer wishes to continue support, or in whom the continued functioning of an MCS prevents their death from other causes, such as a catastrophic neurologic event, or metastatic malignancy.30 This topic should be addressed a priori with patients before discussions about MCS. Particularly with temporary devices, the potential need to either discontinue or to escalate support should be addressed at time of implantation.

Recommendation-Specific Supportive Text

1.	 Durable LVADs should be considered in selected patients with NHYA class IV symptoms who are deemed dependent on IV inotropes or temporary MCS. The magnitude of the survival benefit for durable LVAD support in advanced NYHA class IV patients has progressively improved, with a 2-year survival >80% in recent trials with newer generation LVADs, which approaches the early survival after cardiac transplantation.2 The 2020 INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) report showed that 87.6% of recent durable LVAD recipients were categorized as INTERMACS 1 to 3 before their implant surgery.10 It also showed improved mean survival, >4 years for the destination LVAD cohort, and >5 years for bridge-totransplant patients. Durable LVAD support has also achieved impressive functional improvement and QOL improvement in multiple trials,2,7,31 although patients remain tethered to external electrical power supplies via a percutaneous lead can limit this improvement. Most patients require rehospitalization within the first year post-implant. These factors emphasize the need for a thorough evaluation and patient education before the decision to proceed with the treatment. Appropriate patient selection benefits from review by a multidisciplinary team that typically includes an HF cardiologist, surgeon, social worker, nurse, pharmacist, dietician, and a palliative medicine specialist. 2.	 Durable MCS should be considered in patients with NHYA class IV symptoms despite optimal medical therapy or those deemed dependent on IV inotropes. Destination therapy MCS provides considerable survival advantage in addition to improvement in functional status and healthrelated QOL.1,7,12,32,33 There is no clear 1-risk model to assess patient risk for complications, but factors such as elevated central venous pressure, pulmonary hypertension, and coagulopathy have been linked to poorer outcomes.15,34–36 In patients who are unable to tolerate anticoagulation after repeated challenges, implantation of a durable MCS is associated with excess morbidity; incidents of pump thrombosis, hemolysis, and ischemic neurologic events have been linked to subtherapeutic international normalized ratios.37–41 In addition, implantation of MCS in patients with INTERMACS profile of 1 has been associated with poorer outcome, while those ambulatory patients with profiles 5 to 7 might be too well to have large significant benefit, depending on their symptom burden.19 For patients who are initially considered to be transplant ineligible because of pulmonary hypertension, obesity, overall frailty, or other reasons, MCS can provide time to reverse or modify these conditions.35,42–44 Continuing and uptitrating GDMT in patients with durable MCS is recommended.45

3.	 Multiple studies evaluated the cost-effectiveness of ventricular assist device implantation for advanced HF between 2012 and 2017.20,21,23 They consistently found device implantation was of low economic value, with incremental cost-effectiveness ratios of $200 000 per QALY gained compared with medical therapy alone among patients who potentially underwent subsequent heart transplant and those who were ineligible for heart transplant. In these studies, costs after implantation remained high given high rates of complication and rehospitalization. However, these studies used earlier estimates of post-implant outcomes and complication-related costs that have generally improved over time with better care and newer devices.46–48 Additionally, limited recent data suggest improvement in health care costs and intermediate economic value with LVAD among patients with advanced HF who are either eligible or ineligible for subsequent heart transplant.22,24 The improvement may result from lower complication rates, increased survival, lower implant costs, and higher estimated QOL. However, given the conflicting data and limited analyses of contemporary data, the current value of LVAD therapy is uncertain. 4.	 Temporary MCS can help stabilize patients and allow time for decisions about the appropriateness of transitions to definitive management, such as durable MCS as a bridge or destination therapy, stabilization until cardiac transplantation or, in the case of improvement and recovery, suitability for device removal.45 These patients often present in cardiogenic shock that cannot be managed solely with IV inotropes and in whom other organ function is at risk. Temporary MCS is also appropriate for

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