Heart Transplant & LVAD: End-Stage Heart Failure Treatments

Heart Transplant & LVAD: Hope in End-Stage Heart Failure

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End-stage heart failure is a condition where the heart’s pumping function is severely impaired, patients have difficulty performing daily activities, quality of life is significantly reduced, and life expectancy is shortened. Traditional medication therapies and lifestyle changes are insufficient at this stage. Fortunately, heart transplant and mechanical circulatory support devices (especially LVAD) offer life-saving options for these patients.

Stages of Heart Failure

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Heart failure is evaluated in four stages according to the New York Heart Association (NYHA) classification:

• NYHA Class I: No symptoms with physical activity
• NYHA Class II: Symptoms with mild physical activity
• NYHA Class III: Symptoms with minimal activity, comfortable at rest
• NYHA Class IV: Symptoms even at rest, worsening with any activity

End-stage heart failure generally corresponds to NYHA Class III-IV and shows progressive symptoms despite maximum medical therapy.

What is Heart Transplant?

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Heart transplant (cardiac transplantation) is the procedure of treating a patient with treatment-resistant end-stage heart failure with a healthy heart taken from a donor who has experienced brain death. The first successful human heart transplant was performed by Dr. Christiana Barnard in 1967, and since then techniques, immunosuppressive drugs, and patient care have continuously evolved.

History of Heart Transplant

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Heart transplant history can be divided into several important periods:

• Experimental Period (1905-1967): Animal experiments and technical development
• First Clinical Trials (1967-1980): First successful transplants but high mortality
• Cyclosporine Era (1980s): Dramatic improvement in rejection control and survival with discovery of cyclosporine
• Modern Period (1990s-present): Advanced immunosuppressive drugs, infection control, organ preservation techniques

Current Status of Heart Transplant

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Today, heart transplant is the most effective treatment for end-stage heart failure. Approximately 5,000-6,000 heart transplants are performed worldwide annually. Success rates are continuously improving, with post-transplant life duration and quality enhancing.

Who Gets Heart Transplant? (Indications)

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Heart transplant candidacy requires a detailed evaluation process. General indications include:

Absolute Indications

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1. Advanced heart failure: NYHA Class III-IV symptoms despite maximum medical therapy
2. Cardiogenic shock: Condition requiring intravenous inotropic support or mechanical support
3. Refractory angina: Severe angina unresponsive to medical therapy and not amenable to revascularization
4. Refractory ventricular arrhythmias: Life-threatening arrhythmias uncontrolled despite medical therapy, ablation, and ICD
5. Congenital heart disease: Uncorrectable congenital heart diseases leading to progressive heart failure

Relative Indications

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1. Stable NYHA Class III-IV: But requiring frequent hospitalizations
2. Idiopathic cardiomyopathy: Especially in young patients
3. Ischemic cardiomyopathy: Not improving after revascularization

Contraindications for Transplant (Barriers)

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1. Irreversible pulmonary hypertension: Pulmonary vascular resistance >5 Wood units
2. Active malignancy (cancer): Not in remission for at least 5 years
3. Irreversible kidney, liver, or lung failure
4. Active infection: Not controlled
5. Severe peripheral or cerebrovascular disease
6. Psychiatric illness: Impairing treatment adherence
7. Substance abuse: Active alcohol or drug addiction
8. Advanced age: Generally >65-70 years (relative)

What is LVAD (Left Ventricular Assist Device)?

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LVAD is a mechanical device that supports the pumping function of the left ventricle. It takes blood from the left ventricle and pumps it into the aorta, reducing the heart’s workload. First LVADs were developed in the 1960s but have become safer and more effective with technological advances since the 2000s.

LVAD Working Principle

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LVAD systems typically consist of three main components:

1. Pump: Implanted inside the body, takes blood from left ventricle and pumps to aorta
2. Driveline (power cable): Connects the pump to external controller, exits through abdominal wall
3. Controller and batteries: Carried outside the body, provides power to the device

LVAD Types

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1. Pulsatile Flow LVADs (Older Generation)

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• Pumps blood with pulse-like beats
• Larger, noisier
• Higher thromboembolism risk
• Example: HeartMate XVE

2. Continuous Flow LVADs (Current Generation)

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• Provides continuous, pulseless flow
• Smaller, quieter
• Lower thromboembolism risk
• Example: HeartMate 3, HeartWare HVAD

3. Fully Implantable Systems (Developing)

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• Entire system inside the body
• Transcutaneous energy transfer
• Lower infection risk
• Not yet in widespread clinical use

LVAD Indications

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Bridge-to-Transplant (BTT)

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• Provide support for patients on transplant list until organ becomes available
• Keep patient suitable for transplant
• Reduce intensive care need

Destination Therapy (DT)

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• Provide permanent support for patients not eligible for transplant
• Generally >65 years or patients with transplant contraindications
• Increase life expectancy and quality

Bridge-to-Decision

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• Provide stabilization for patients with acute hemodynamic collapse
• Gain time to evaluate transplant eligibility

Bridge-to-Recovery

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• Support for patients with reversible heart failure (myocarditis, postpartum cardiomyopathy)
• Provide support for heart to heal itself
• Rare (5-10%)

Heart Transplant vs LVAD: Which Treatment is More Appropriate?

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Treatment choice is individualized based on patient characteristics, available resources, and patient preferences.

Heart Transplant Advantages

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1. Long-term survival: Average 10-15 years
2. Better quality of life: No device dependence
3. Normal physiology: Natural heart, normal pulse
4. Psychological advantage: Feeling “normal”
5. Less medication burden: Immunosuppressive drugs can be reduced over time

Heart Transplant Disadvantages

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1. Organ shortage: Long waiting times
2. Mortality while waiting: 10-20%
3. Lifelong immunosuppressive drugs: Side effects and infection risk
4. Chronic rejection risk: Long-term graft function loss
5. Donor heart quality: Dependent on donor characteristics

LVAD Advantages

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1. Early applicability: No need to wait for organ
2. Reduces waiting list mortality: For transplant candidates
3. Treatment option for non-transplant candidates: Destination therapy
4. Technological advances: Devices becoming safer
5. Supports recovery in reversible conditions

LVAD Disadvantages

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1. Device dependence: Continuous batteries, check-ups
2. Complication risk: Bleeding, infection, stroke
3. Quality of life restrictions: Water activities, magnetic fields
4. Device noise and vibration: Bothersome for some patients
5. Driveline care: Infection risk

Decision-Making Process

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Treatment decision is made by a multidisciplinary team (cardiologist, cardiac surgeon, psychologist, social worker). Evaluation criteria:

1. Patient age: <65 generally transplant, >65 generally LVAD (destination therapy)
2. Comorbidities: Suitability for transplant
3. Social support: Adequacy for LVAD care
4. Psychological status: Treatment adherence
5. Patient preference: Informed decision

Pre-Transplant Evaluation Process

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Transplant candidate patients undergo comprehensive evaluation. This process usually takes 1-2 weeks.

Medical Evaluation

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1. Cardiac tests:

   • Echocardiography (EF, valve function, pressures)
   • Right heart catheterization (pulmonary hypertension evaluation)
   • Coronary angiography (coronary artery disease)
   • Endomyocardial biopsy (myocarditis differential diagnosis)

2. Systemic evaluation:

   • Pulmonary function tests
   • Liver and kidney function tests
   • Diabetes screening
   • Cancer screening (mammography, colonoscopy, PSA)

3. Infection screening:

   • Hepatitis B, C serology
   • HIV test
   • CMV, EBV, toxoplasma serology
   • Tuberculin skin test or IGRA

Psychosocial Evaluation

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1. Psychiatric evaluation: Depression, anxiety, treatment adherence
2. Social support analysis: Family support, available caregiver
3. Financial evaluation: Treatment costs, insurance coverage
4. Education: Transplant process, medications, follow-up requirements

Placement on Transplant List

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Evaluation results are reviewed by transplant team. Suitable patients are placed on transplant waiting list. List priorities:

1. Status 1A: In intensive care, mechanical support or high-dose inotropes
2. Status 1B: Stable with LVAD or moderate-dose inotropes
3. Status 2: At home, stable with oral medications
4. Status 7: Temporarily inactive (infection, financial issues)

LVAD Implantation: Surgical Process

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LVAD implantation is a complex cardiac surgery procedure lasting average 4-6 hours.

Preoperative Preparation

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1. Anesthesia evaluation: Risk factors, intubation plan
2. Transesophageal echocardiography: Guidance during surgery
3. Blood products preparation: Transfusion possibility
4. Antibiotic prophylaxis: Infection prevention

Surgical Technique

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1. Sternotomy: Midline opening of chest
2. Cardiopulmonary bypass: Connection to heart-lung machine
3. Pump placement: Usually above diaphragm, in pericardial space
4. Inflow cannula placement: To left ventricular apex
5. Outflow graft placement: Anastomosis to aorta
6. Driveline exit: Through abdominal wall via subcutaneous tunnel
7. Separation from bypass: LVAD activated, heart supported
8. Bleeding control and closure

Postoperative Care

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1. Intensive care: 3-7 days
2. Respiratory support: Usually 24-48 hours mechanical ventilation
3. Hemorrhagic shock treatment: Bleeding control, transfusion
4. Right heart failure management: Inotropic support, pulmonary vasodilators
5. LVAD settings: Speed, flow optimization
6. Anticoagulation: Heparin, later warfarin
7. Infection prophylaxis: Antibiotics, driveline care education

Heart Transplant Surgery

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Heart transplant operation lasts average 4-8 hours and requires high-level expertise.

Organ Procurement and Preservation

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1. Donor selection: Age, comorbidities, cardiac function
2. Organ procurement: After brain death under aseptic conditions
3. Preservation solution: Heart arrested, perfused with cold preservation solution
4. Cold ischemia time: Ideal <4 hours, maximum 6 hours

Recipient Preparation

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1. Sternotomy: Recipient prepared until donor heart arrives
2. Cardiopulmonary bypass: Connection to heart-lung machine
3. Recipient heart removal: Atrial cuffs left behind

Implantation Technique

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1. Biatrial technique: Part of atria preserved, anastomosis performed

   • Left atrial anastomosis
   • Right atrial anastomosis
   • Aortic anastomosis
   • Pulmonary artery anastomosis

2. Bicaval technique: All atria removed, vena cava anastomoses performed

   • Better atrial function
   • Lower arrhythmia risk
   • Longer operation time

3. Separation from bypass: New heart revived, bypass terminated

4. Pacemaker wires: For temporary pacemaker

5. Bleeding control and closure

Post-Transplant Intensive Care

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1. Immunosuppression initiation: Induction therapy (ATG, basiliximab)
2. Hemodynamic monitoring: Swan-Ganz catheter
3. Respiratory support: Early extubation targeted
4. Renal protection: Fluid balance, avoiding nephrotoxic drugs
5. Infection prophylaxis: Antibiotic, antiviral, antifungal
6. Rejection monitoring: Endomyocardial biopsy (weekly first month)

Postoperative Care and Follow-up

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Heart Transplant Follow-up

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First 3 Months (Frequent Follow-up Period)

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1. Weekly check-ups: Biopsy, laboratory, echocardiography
2. Immunosuppressive medication adjustments: Blood levels (tacrolimus, cyclosporine)
3. Infection screening: CMV, EBV, bacterial infections
4. Rehabilitation: Gradual activity increase

3-12 Months

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1. Biweekly, then monthly check-ups
2. Biopsy frequency decreases: Monthly, then every 3 months
3. Coronary angiography: Annual (for chronic rejection)
4. Lifestyle adjustments: Diet, exercise, infection protection

After 1 Year

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1. Every 3-6 month check-ups
2. Low-dose immunosuppressive maintenance
3. Long-term complication screening: Renal failure, hypertension, diabetes, malignancy

LVAD Follow-up

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First 30 Days (Strict Follow-up)

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1. 2-3 times weekly check-ups: INR monitoring, device parameters
2. Driveline care education: Aseptic technique
3. Rehabilitation: Walking, daily activities
4. Psychological support: Device adaptation

1-6 Months

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1. Weekly, then biweekly check-ups
2. LVAD parameter optimization: Speed, flow
3. Complication screening: Bleeding, infection, stroke
4. Quality of life assessment: Psychosocial support

After 6 Months

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1. Monthly check-ups
2. Long-term complication management: Gastrointestinal arteriovenous malformations, device thrombosis
3. Travel arrangements: Battery backups, center information
4. Family education: Emergency management

Success Rates and Life Expectancy

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Heart Transplant Success Rates

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According to current international data (ISHLT 2023):

• 30-day survival: 94%
• 1-year survival: 88%
• 5-year survival: 73%
• 10-year survival: 53%
• Median survival: 12.5 years

Factors Affecting Survival

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1. Recipient factors:

   • Age (younger > older)
   • Comorbidities (diabetes, kidney failure)
   • Pre-transplant mechanical support
   • Panel reactive antibody (PRA) level

2. Donor factors:

   • Age (younger > older)
   • Ischemia time (<4 hours > >4 hours)
   • Sex mismatch (male donor > female recipient risky)

3. Environmental factors:

   • Transplant center experience
   • Immunosuppressive protocol
   • Follow-up frequency and quality

LVAD Success Rates

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According to INTERMACS registry (2023):

LVAD for Bridge-to-Transplant (BTT)

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• 1-year survival: 86%
• 2-year survival: 78%
• Transplant achievement rate: 65-70%

LVAD for Destination Therapy (DT)

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• 1-year survival: 82%
• 2-year survival: 70%
• 5-year survival: 45%

LVAD Complication Rates (1-year)

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• Major bleeding: 25-30%
• Stroke: 10-15%
• Driveline infection: 20-25%
• Device malfunction: 5-10%

Risks and Complications

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Heart Transplant Complications

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Early Period (0-30 days)

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1. Primary graft dysfunction: Inadequate function of transplanted heart (5-10%)
2. Hyperacute rejection: First 24 hours after transplant, antibody-mediated
3. Technical complications: Bleeding, anastomotic stenosis
4. Right heart failure: Secondary to pulmonary hypertension
5. Renal failure: Cardiopulmonary bypass effect
6. Infection: Bacterial, viral, fungal

Intermediate Period (1-12 months)

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1. Acute cellular rejection: Most common within first 6 months
2. CMV infection: Most common viral infection
3. B-cell lymphoproliferative disease: EBV-associated lymphoma
4. Cardiac allograft vasculopathy: Chronic rejection form
5. Medication side effects: Nephrotoxicity, neurotoxicity, hypertension, diabetes

Late Period (>1 year)

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1. Chronic rejection: Allograft vasculopathy, cardiomyopathy
2. Malignancy: Skin cancers, lymphoma, solid organ tumors
3. Cardiovascular disease: Hypertension, dyslipidemia
4. Bone diseases: Osteoporosis, avascular necrosis
5. Renal failure: Chronic kidney disease (40-50% at 10 years)

LVAD Complications

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Bleeding

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• Gastrointestinal arteriovenous malformations: 20-30%
• Intracranial hemorrhage: 5-10%
• Driveline bleeding: Rare

Thromboembolic Events

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• Stroke: Ischemic or hemorrhagic (10-15%/year)
• Pump thrombosis: 2-8%/year
• Systemic embolism: Spleen, kidney, mesenteric

Infection

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• Driveline infection: Most common (20-25%)
• Pump pocket infection: Serious, may require surgical debridement
• Sepsis: Bacterial, fungal

Device-Related Complications

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• Device failure: Pump stop, component separation
• Driveline tear: Requires emergency surgery
• Sucking: Ventricular wall adherence to inflow cannula
• Arrhythmias: Ventricular tachycardia, fibrillation

Right Heart Failure

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• Acute postoperative: 20-30%
• Late period: Right ventricular remodeling after LVAD

Quality of Life and Psychosocial Dimension

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Quality of Life After Heart Transplant

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Heart transplant provides dramatic improvement in quality of life:

1. Physical function: Returns to NYHA Class I-II
2. Energy level: Significant increase
3. Psychological well-being: Reduction in depression and anxiety
4. Social functioning: Return to work, social activities
5. Sexual function: Usually returns to normal

However, side effects of immunosuppressive drugs (tremor, hirsutism, gingival hyperplasia) may negatively affect quality of life.

Quality of Life After LVAD

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LVAD patients’ quality of life also significantly improves compared to pre-implantation:

1. Symptom improvement: Shortness of breath, fatigue decrease
2. Functional capacity: Increase in 6-minute walk test
3. Hospitalization frequency: Significant reduction

However, device dependence, continuous battery charging, driveline care, and fear of complications can be sources of psychological stress.

Psychosocial Support Need

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Both treatments require psychosocial support:

1. Patient education: Treatment process, medications, emergencies
2. Family support: Caregiver education
3. Psychological counseling: Adaptation process, anxiety management
4. Support groups: Communication with patients with similar experiences
5. Vocational rehabilitation: Return-to-work support

Future Perspectives and Innovations

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Innovations in Heart Transplant

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1. Ex-vivo heart perfusion: Transporting organs kept alive, extending ischemia time
2. HLA matching: Better tissue compatibility, reducing rejection risk
3. Tolerance induction: Graft acceptance without need for immunosuppressive drugs
4. Xenotransplantation: Pig heart transplant (with genetic modification)
5. Bio-artificial hearts: Hearts produced through tissue engineering

Developments in LVAD Technology

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1. Fully implantable systems: Transcutaneous energy transfer
2. Miniaturization: Smaller pumps, minimally invasive implantation
3. Smart LVADs: Automatic speed adjustment, early warning systems for complications
4. Biological surface coatings: Reducing thrombogenicity
5. Battery technology: Longer-lasting, rechargeable batteries

Artificial Heart Technology

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Total artificial hearts (TAH) support both ventricles:

1. SynCardia TAH: Temporary support, for patients awaiting transplant
2. Carmat TAH: Biological surface, pulsatile flow
3. Aeson TAH: Continuous flow, fully implantable

Frequently Asked Questions (FAQ)

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When to See a Doctor?

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Consult a cardiology specialist without delay if you experience:

1. Shortness of breath at rest or with minimal activity
2. Waking up at night with cough or shortness of breath
3. Swelling in ankles, legs, or abdomen
4. Loss of appetite, nausea, weight loss
5. Mental confusion, difficulty concentrating
6. Palpitations, chest pain, or fainting
7. Worsening of existing heart failure symptoms
8. For LVAD patients: Alarm sounds, driveline changes, fever, bleeding

Especially if you have NYHA Class III-IV heart failure diagnosis and your symptoms continue despite maximum medical therapy, it is important to consult a heart failure center for heart transplant or LVAD evaluation.

Schedule an Appointment

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You can schedule an appointment for evaluation and information about end-stage heart failure, heart transplant, or LVAD treatment.