Left Ventricular Assist Devices (LVADS): History, Clinical Application and Complications

Abstract

Congestive heart failure is a major cause of morbidity and mortality as well as a major health care cost in the developed world. Despite the introduction of highly effective heart failure medical therapies and simple devices such as cardiac resynchronization therapy that reduce mortality, improve cardiac function and quality of life, there remains a large number of patients who do not respond to these therapies or whose heart failure progresses despite optimal therapy. For these patients, cardiac transplantation is an option but is limited by donor availability as well as co-morbidities which may limit survival post-transplant. For these patients, left ventricular assist devices (LVADs) offer an alternative that can improve survival as well as exercise tolerance and quality of life. These devices have continued to improve as technology has improved with substantially improved durability of the devices and fewer post-implant complications. Pump thrombosis, stroke, gastrointestinal bleeding and arrhythmias post-implant have become less common with the newest devices, making destination therapy where ventricular assist device are implanted permanently in patients with advanced heart failure, a reality and an appropriate option for many patients. This may offer an opportunity for long term survival in many patients. As the first of the totally implantable devices are introduced and go to clinical trials, LVADs may be introduced that may truly be alternatives to cardiac transplantation in selected patients. Post-implant right ventricular failure remains a significant complication and better ways to identify patients at risk as well as to manage this complication must be developed.

Trends in HeartMate 3: What we know so far

“…3 Among these devices was the Thoratec pneumatic VAD (Thoratec Corp), one of the first VADs be approved by the FDA as a BTT, which became the Thoratec XVE, colloquially referred to as the HeartMate I. 3 Other first-generation assist devices were developed, and by 2008, the FDA had approved durable devices for adults including the HeartMate IP, HeartMate VE, HeartMate XVE, Thoratec IVAD, Thoratec PVAD (Thoratec Corp), NovaCor PC, and NovaCor PCq (WorldHeart Inc., Oakland, CA). 8 Second-generation devices that were no longer pulsatile quickly followed.…”

“…1 Over one million hospitalizations and 600 000 deaths annually are a result of heart failure, making it the leading cause of morbidity and mortality in the US. 2,3 Approximately 5% of these patients have New York Heart Association class IV symptoms and are eligible for advanced therapies, including heart transplantation and left ventricular assist device (LVAD) support. 3 Thus, there are 300 000 people each year requiring heart transplantations; however, in 2018, there were only 3408 heart transplants in the US.…”

“…2,3 Approximately 5% of these patients have New York Heart Association class IV symptoms and are eligible for advanced therapies, including heart transplantation and left ventricular assist device (LVAD) support. 3 Thus, there are 300 000 people each year requiring heart transplantations; however, in 2018, there were only 3408 heart transplants in the US. 3,4 This number has not changed significantly in the last 30 years secondary to a lack of suitable donor organs.…”

Pericardial release for early LVAD malalignment a less invasive approach

“…1 Mechanical circulatory support is often a necessary therapy for those who fail medical management. 2,3 While durable left ventricular assist device (LVAD) is a sustainable option for many patients, 4,5 the pitfalls of these therapies should be described to offer solutions to potentially recurring problems. Only through optimizing medical and surgical management options, can we continue to improve the lives of the patients on the continuum of cardiogenic shock and end-stage heart failure.…”

“…Cardiogenic shock is a state of low cardiac output resulting in life‐threatening end‐organ hypoperfusion and hypoxia 1 . Mechanical circulatory support is often a necessary therapy for those who fail medical management 2,3 . While durable left ventricular assist device (LVAD) is a sustainable option for many patients, 4,5 the pitfalls of these therapies should be described to offer solutions to potentially recurring problems.…”