IJCS | Volume 32, Nº1, January/ February 2019

89 Table 1 - FDA indications for Total Artificial Heart (Syncardia) inclusion and exclusion criteria 1 Inclusion criteria: Exclusion criteria: Eligible for transplantation Use of any vascular assist device New York Heart Association (NYHA) class IV Pulmonary vascular resistance ≥ 8 Wood units 
(640 dyne.sec.cm - 5 ) Body surface area 1.7–2.5 m 2 , or T10 ≥ 10 cm (distance on computed tomographic scan from the anterior vertebral body to the sternum inner table at the level of the 10th thoracic vertebra) Dialysis in previous 7 days Hemodynamic insufficiency demonstrated by A or B: Serum Creatinine level ≥ 5 mg/dL A. Cardiac index ≤ 2 L/min/m 2 and one of the following: - Systolic arterial pressure ≤ 90 mmHg - Central venous pressure ≥ 18 mmHg Cirrhosis and/or total bilirubin level ≥ 5 mg/dL B. Two of the following: 
 - Dopamine ≥ 10 μg/kg/min - Dobutamine ≥ 10 μg/kg/min - Epinephrine ≥ 2 μg/kg/min - Isoproterenol ≥ 2 μg/kg/min - Milrinone ≥ 0.5 μg/kg/min Other drugs at toxic levels. Intra-aortic balloon pump, cardiopulmonary bypass. Cytotoxic antibody ≥ 10% Rico et al. Terminal AHF due to electrical storm:TAH orVAD Int J Cardiovasc Sci. 2019;32(1)87-90 Case Report was also considered, but the arrhythmogenic ventricle was always a great concern. For that reason, a novel alternative therapy was pursued: the implantation of a total artificial heart (SynCardia) as a BTT. This was successfully done and the patient is now stable and on a waiting list for heart transplantation. Discussion Advanced heart failure with reduced ejection fraction remains a clinical dilemma in the medical world. Despite optimal medical therapy, cardiac resynchronization and ICD, there is a large population of patients that fail to compensate for the disease and demand heart transplantation. Due to low availability of heart transplantation, ventricular assist device (VAD) provides the mechanical circulatory support needed by these patients, as a bridge to transplant. In relation to our patient, decisions concerning the different types of VADs were made taking into account that right ventricular dysfunction and uncontrolled arrhythmias are a major limiting factor for LVAD use, making TAH a better option to maintain circulatory support in such case. A TAH was the most suitable option; LVAD limitations in this patient were right ventricular dysfunction and incessant ventricular refractory arrhythmias. 2,3 Mechanical support therapies are alternative therapies for BTT patients who do not have an available heart donor. Nowadays, the industry provides several novel heart failure devices. 4 Most of them are intended to provide additional flow support, either continuous or pulsatile, for achieving temporary flow support. However, novel therapies, such as the TAH, have aimed to provide a long-term support even in the outpatient setting, with the great advantage of supplying the patient with fully autonomous ventricular function, making it a quite suitable option if no transplant is immediately available and for those patients with refractory, life- threatening malignant ventricular arrhythmias. 5 Interestingly, the patient described in our case report did not fit the guidelines, which made him a candidate for hemodynamic support with assist devices, but the main issue was to choose the most beneficial therapy. The TAH, commonly known by the brand name “SynCardia”, is a device option for patients with end- stage heart failure, particularly those with biventricular heart failure with no response to other assisted therapies. The FDA approved the device in 2004 as a BTT for biventricular failure. Table 1 shows all FDA- approved indications. 6 Therefore, its use has been slowly increasing due to the lack of implantation experience and clear guidelines supporting the indications, in addition to the absence of worldwide consensus and