All authors express their thanks for the important addition in Dr. Gerlach’s and Prof. Weber’s comments. It should be clearly emphasized that multidisciplinary treatment of patients with terminal heart failure with permanent implantable cardiac support systems by far exceeds the scope of surgical and cardiological care. Method-related physical impairments, complications, and therapeutic failures require more intense support from relatives and treating physicians—in the clinical as well as the domestic setting. In the sense of advance care planning, a treatment plan should be developed even before the implantation by the team consisting of the patient, their relatives, and treating physicians. Unrealistic therapeutic goals (cure or heart transplantation) should primarily not be in the offing in this setting. A proxy for power of attorney should be nominated early and should be involved in all phases of the treatment. On the occasion of the first presentation, the option of palliative care in the sense of best supportive care should be raised in the team as a valid, alternative treatment pathway. A decisive patient’s advance directive should be written up early.
If patients with mechanical circulatory support enter the phase of heart failure, in which they require palliative care, it should be borne in mind that the process of dying is defined not only by internal degradation processes but can also depend on the function of the support system. In this phase, advanced treatment planning can help cushion the extreme psychosocial stress that arises for all involved when mechanical circulatory support treatment is stopped.
The recently published consensus report of the European Association of Cardio-Thoracic Surgery (EACTS)—which we cited in our article—dedicates an entire “End of Life Care” chapter to these important aspects (2).
Prof. Dr. med. René Schramm, PhD
Klinik für Thorax- und Kardiovaskularchirurgie
Herz- und Diabeteszentrum NRW
Universitätsklinik der Ruhr-Universität Bochum
Conflict of interest statement
Prof. René Schramm has received speaker honoraria and travel expense reimbursement from Abbott.
|1.||Gummert JF, Haverich A, Schmitto JD, Potapov E, Schramm R, Falk V: Permanent implantable cardiac support systems. Dtsch Arztebl Int 2019; 116: 843–8 VOLLTEXT|
|2.||Potapov EV, Antonides C, Crespo-Leiro MG, et al.: 2019 EACTS expert consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56: 230–70 CrossRef|