Best of heart failure

34 presentation that is most commonly due to non-cardiac causes. The true inci- dence of ischemic chest pain during LVAD support remains undefined, but ischemia may nevertheless be a possible cause of pain in these patients. Acute MI can occur in LVAD patients and may be due to coronary plaque rupture, paradoxical thromboembolism, LV or aortic root thromboembolism, and im- paired myocardial perfusion due to elevated LV filling pressures secondary to LVAD failure. Left heart catheterization should be performed only after carefully weighing the risks and potential benefits and by operators with experience in durable mechanical support. Potential benefits of coronary intervention for patients with LVAD include symptom relief, prevention of arrhythmogenesis, reduction of ongoing myocardial damage, and support of RV function. Future studies are necessary to evaluate the benefit of revascularization in the setting of LVAD support, especially as the number of patients receiving LVADs as “ bridge to decision ” and “ destination therapy ” continue to grow. Whether coronary revascularization in LVAD patients with severely depressed LV systolic function who demonstrate myocardial viability impacts clinical outcomes remains unknown. Heart-team approach in patients with advanced heart failure undergoing revascularization Growth in three major cardiac device domains has helped to shape contem- porary practice around advanced HF. A landmark study identified that the Heartmate II (Thoratec, Pleasanton, CA) rotary flow LVAD demonstrated su- perior clinical outcomes compared with pulsatile LVADs for patients with advanced HF, triggering immense growth in the use of LVADs amongst HF specialists and cardiac surgeons. Around the same time, AMCS device and newer generation stents used within the interventional cardiology community were growing mainly for high-risk percutaneous coronary intervention. Finally, there has been improvement in “ off-pump ” surgical techniques and increasing use of arterial conduits for CABG. Ever-expanding device development and improving surgical and percutaneous techniques have led to the creation of heart teams at tertiary medical centers. This unique collaboration should be applied universally to patients with advanced HF undergoing revascularization procedures. Communication and collaboration amongst a team consisting of HF and cardiac transplantation specialists, interventional cardiologists, cardiac surgeons, intensivists, and others are fundamental to optimizing clinical out- comes in this challenging patient population [ 26 ]. The interventionalist offers invasive hemodynamic assessment, coronary revascularization, and possibly AMCS for LV, RV, or biventricular failure. The cardiac surgeon manages post-MI mechanical complications and surgical coronary revascularization if PCI is not an option, to assist with initiation of AMCS or VA-ECMO and to provide input regarding candidacy for LVAD or orthotopic heart transplantation (OHTx). The advanced HF specialist also assists with evaluating a patient ’ s candidacy for LVAD or OHTx in addition to optimizing hemodynamics, managing AMCS or VA-ECMO, and providing input regarding end-of-life decision-making, pallia- tion, and medical futility. The cardiac intensivist further assists with hemody- namic optimization and AMCS device management and provides input on the Curr Treat Options Cardio Med (2019) 21: 4 Page 9 of 12 4