Key Features

• Treatment for advanced heart failure refractory to goal directed medical therapy includes: heart transplantation, long term mechanical circulatory support, and long term inotropic drug therapy. Heart transplantation is limited by donor organ availability and recipient candidacy. Long term inotropic drug therapy does not improve survival but can be used as a bridge to other therapies or symptom palliation.
• MCS device intent at the time of implantation has traditionally been classified as bridge to transplant (BTT), destination therapy (DT), bridge to candidacy (BTC), or bridge to recovery (BTR). There is significant crossover between groups. Notably, BTT patients may have a prolonged wait, never receive a transplant, recover to explant, or become ineligible. DT patients may similarly recover to explant or overcome prior contraindications to transplant.
• DT is the most common indication for LVAD. This markedly increased in the United States with the 2018 UNOS policy change in heart allocation.
• MCS technology has evolved from mechanically complex large pulsatile devices to more durable smaller continuous flow rotary devices. This has been associated with decreased adverse events and improved survival.
• Long term (durable) MCS is limited by adverse events including bleeding, thromboembolism, infection, stroke, and RV failure.
• The primary dischargeable LVAD currently used in the US for short and long term support is the Heartmate 3 (Abbott, Chicago, IL), a centrifugal continuous flow LVAD with a magnetically levitated rotor.
• The total artificial heart (TAH) is indicated in a small subset of patients requiring BTT MCS not amenable to isolated left ventricular support. Indications include: advanced biventricular systolic dysfunction, refractory arrhythymias, restrictive / hypertrophic cardiomyopathies, congenital heart disease, and significant other intracardiac defects.