Left ventricular assist devices as destination therapy in stage D heart failure

Mechanical circulatory support (MCS) has increasingly become an important management opportunity for patients with stage D heart failure (HF) with remarkable impact on patient survival and quality of life. Early clinical trials have demonstrated improved outcomes of durable left ventricular assist device (LVAD) support compared with optimal medical management. As technology advanced, continuous flow LVADs outperformed pulsatile flow devices in clinical trials and the field migrated to HeartMate (Abbott Laboratories, Abbott Park, IL) and HeartWare (Medtronic, Minneapolis, MN) devices due to their clinical superiority. Among the continuous flow devices, axial flow and centrifugal flow with magnetic levitation (MagLev) designs were subsequently investigated in clinical trials with promising findings. Compared with a survival rate of 54% with the first-generation pulsatile-flow HeartMate XVE LVADs, survival has improved to 76% and 83% with implantation of the second-generation axial-flow HeartMate II and the third-generation centrifugal-flow HeartMate III LVADs respectively, after two years of follow-up post LVAD implantation. Furthermore, minimal invasive procedures as alternatives to sternotomy for device placement, such as lateral thoracotomy, have been explored to improve postoperative recovery and long-term outcomes. Presently, the Food and Drug Administration (FDA) approved devices include the axial flow HeartMate II, centrifugal flow with passive MagLev design of HeartWare, and centrifugal flow with a fully MagLev design of HeartMate III. All of these devices are FDA approved for patient who are supported with an LVAD while they await heart transplantation (HT) [bridge-to-transplant (BTT)] as well as for patients who are