The History of Durable Left Ventricular Assist Devices and Comparison of Outcomes: HeartWare, HeartMate II, HeartMate 3, and the Future of Mechanical Circulatory Support

Antithrombotic Treatment for Left Ventricular Assist Devices: One Does Not Fit All

As the prevalence of heart failure is increasing globally, left ventricular assist devices (LVADs) have become essential therapeutic options in managing advanced heart failure. This review explores the development of LVAD technology, with a focus on the shift from pulsatile to continuous-flow devices, particularly the HeartMate 3, the most advanced generation of LVADs. The evolution in design has significantly enhanced patient survival and quality of life. However, hemocompatibility-related adverse events (HRAEs)-such as pump thrombosis, ischemic and hemorrhagic strokes, and gastrointestinal bleeding-remain major clinical challenges. Striking the delicate balance between preventing thromboembolic events and minimizing hemorrhagic risks remains critical in LVAD patient management. Current therapeutic strategies typically involve long-term anticoagulation with vitamin K antagonists and antiplatelet therapy, though optimal management must be individualized based on patient-specific factors and device characteristics. Emerging alternatives, including low-dose anticoagulation, direct oral anticoagulants such as apixaban, and aspirin-free regimens, offer promising potential to reduce adverse outcomes. This review also highlights the role of innovative mechanical designs in minimizing shear stress and alternative treatments in preventing complications like gastrointestinal bleeding. Despite these advancements, personalized treatment strategies are critical, as no single therapeutic regimen fits all LVAD recipients. Ongoing research into both device technology and pharmacological therapies is essential to further reduce HRAEs and improve long-term outcomes for LVAD patients.

Outcomes of Left Ventricular Assist Devices as Destination Therapy: A Systematic Review with Meta-Analysis

BACKGROUND

Heart failure (HF) is a chronic condition that significantly affects morbidity and mortality. For patients with end-stage HF who are not candidates for heart transplantation, left ventricular assist devices (LVADs) provide mechanical circulatory support as a long-term solution, known as destination therapy (DT).

OBJECTIVE

This meta-analysis aims to synthesize evidence on the survival rates, complications, and quality-of-life improvements associated with LVADs used as destination therapy in patients with end-stage HF.

METHODS

A systematic search of databases, including PubMed, Embase, Cochrane Library, Web of Science, and Scopus, was conducted to identify relevant studies. Studies were selected based on predefined inclusion and exclusion criteria. Data from 12 studies were extracted and analyzed using a random-effects model. Survival rates, complications (e.g., infection and bleeding), and quality-of-life measures were the primary outcomes evaluated.

RESULTS

The analysis showed significant improvements in survival, with a pooled effect size of 0.848 (95% CI: 0.306-1.390, p = 0.002). Complication rates varied, with infections and bleeding being the most common adverse events. Quality of life also improved significantly post-LVAD implantation, with a standardized mean difference of 0.78 (95% CI: 0.65-0.91).

CONCLUSIONS

LVADs as destination therapy provide a viable option for improving the survival and quality of life of end-stage HF patients, despite the associated risks of complications. Further research is needed to refine patient selection and management strategies to optimize outcomes.

Recent Developments in Ventricular Assist Device Therapy

The evolution of left ventricular assist devices (LVADs) from large, pulsatile systems to compact, continuous-flow pumps has significantly improved implantation outcomes and patient mobility. Minimally invasive surgical techniques have emerged that offer reduced morbidity and enhanced recovery for LVAD recipients. Innovations in wireless power transfer technologies aim to mitigate driveline-related complications, enhancing patient safety and quality of life. Pediatric ventricular assist devices (VADs) remain a critical unmet need; challenges in developing pediatric VADs include device sizing and managing congenital heart disease. Advances in LVAD technology adapted for use in right ventricular assist devices (RVADs) make possible the effective management of right ventricular failure in patients with acute cardiac conditions or congenital heart defects. To address disparities in mechanical circulatory support (MCS) access, cost-effective VAD designs have been developed internationally. The Vitalmex device from Mexico City combines pulsatile-flow technology with a paracorporeal design, utilizing cost-effective materials like silicone-elastic and titanium, and features a reusable pump housing to minimize manufacturing and operational costs. Romanian researchers have used advanced mathematical modeling and three-dimensional (3D) printing to produce a rim-driven, hubless axial-flow pump, achieving efficient blood flow with a compact design that includes a wireless power supply to reduce infection risk. In conclusion, MCS continues to advance with technological innovation and global collaboration. Ongoing efforts are essential to optimize outcomes, expand indications, and improve access to life-saving therapies worldwide.

Pregnancy with a Left Ventricular Assist Device: A Narrative Review

ABSTRACT

This narrative review discusses the various challenges associated with the presence of a left ventricular assist device (LVAD) during pregnancy. Given the hemodynamic and coagulation changes associated with pregnancy, the presence of an LVAD adds a layer of complexity with respect to optimal management. This review will discuss the anesthetic considerations when dealing with this subset of patients who may have other comorbidities alongside their advanced heart failure. Additionally, this paper aims to review successful pregnancies with an LVAD placement focusing on the mode of delivery and hemodynamic management risk.

The Impact of Genetic Polymorphism on Complication Development in Heart Failure Patients

Background: Despite the high progress that has been made in the field of cardiology, the left ventricular assist device (LVAD) can still cause complications (thrombosis/bleeding) in heart failure (HF) patients after implantation. Complications develop due to the incorrect dose of antithrombotic therapy, due to the influence of the non-physiological shear stress of the device, and also due to inherited genetic polymorphisms. Therefore, the aim of our study is to identify the influence of the genetic polymorphisms on complication development in HF patients with implanted LVADs with prescribed antiplatelet therapy. Methods: Our study investigated 98 HF patients with/without complications who were genotyped for 21 single-nucleotide polymorphisms (SNPs) associated with cardiovascular events, the coagulation system, and the metabolism of warfarin and aspirin drugs. This study performed a more detailed analysis on genetic polymorphism in the UGT1A6 gene and its influence on aspirin dose. Results: SNP rs2070959 in the UGT1A6 gene showed a significant association with the group of HF patients with complications [(OR (95% CI): 4.40 (1.06-18.20), p = 0.044]. The genetic polymorphism of rs2070959 in the UGT1A6 gene showed a significant association in HF patients who received aspirin treatment on the 12th month after LVAD implantation [OR (95% CI): 5.10 (1.31-19.87), p = 0.018]. Moreover, our genotype distribution analysis showed that the GG genotype of rs2070959 in the UGT1A6 gene was significantly higher in the group with aspirin treatment than without treatment after the 12th month of treatment (50.0% vs. 0%, p = 0.008), especially in the group of patients with complications. A higher frequency of the GG genotype with long-lasting aspirin therapy up to the 12th month showed that 100 mg of aspirin was not an effective dose in the group of patients with complications. Conclusions: Our study identified that genotyping for genetic polymorphism rs2070959 in the UGT1A6 gene could predict the recommended dose of aspirin in HF patients, which could help to prevent and predict complication development after LVAD implantation.

Survival of a patient following initial left ventricular assist device implantation and two successive left ventricular assist device exchanges: case report

Background

Initially conceptualized as a bridge to heart transplantation, the left ventricular assist device (LVAD) has become an important option for improving survival in patients with severe heart failure and poor prognosis.

Case summary

We report the case of a patient suffering from severe chronic heart failure, complicated by ST-elevation myocardial infarction due to left main coronary artery stenosis (NYHA IV, INTERMACS profile 1). Despite support with veno-arterial extracorporeal membrane oxygenation, inotropes, and catecholamine therapy, the patient's cardiac function did not recover sufficiently. Consequently, the decision was made to proceed with LVAD implantation as destination therapy. The initial LVAD implantation was uneventful, and the patient received anticoagulant therapy according to standard operating procedure. However, pump thrombosis occurred on the first post-operative day, necessitating an LVAD exchange. Following an extended stay in the cardiac surgery intensive care unit, the patient was eventually discharged. Approximately 15 months later, the patient developed a driveline infection, involving most of the intrapericardial components of the LVAD. A second LVAD exchange was required, and the patient received a third LVAD. To mitigate the risk of recurrent infection, suppressive antibiotic therapy with ampicillin/sulbactam was initiated.

Discussion

This is the first reported case of a patient surviving three LVAD implantations and highlights an instance of off-label use of lifelong antibiotic therapy following a driveline infection.

Left Ventricular Assist Device in Advanced Refractory Heart Failure: A Comprehensive Review of Patient Selection, Surgical Approaches, Complications and Future Perspectives

The management of advanced heart failure (HF) has long posed significant challenges due to its complex and chronic nature. Heart transplantation, while effective, is not always feasible due to the limited availability of donor organs. In this context, long term mechanical circulatory support and mainly left ventricular assist devices (LVADs) have emerged as a vital intervention to fill this gap. LVAD superiority compared to medical therapy for some patients in advanced heart failure has been demonstrated either as a bridge to transplantation or as destination therapy. This literature review provides a comprehensive overview of the effectiveness, challenges, and advancements in the use of LVADs for treating advanced heart failure. It evaluates clinical outcomes associated with LVAD therapy, focusing on survival rates and quality of life improvements. The review synthesizes findings from recent studies, highlighting both the benefits and complications of LVAD implantation, such as infectious risk, thromboembolic events, hemorrhage and device malfunction. Additionally, it explores the latest technological and biomedical advancements in LVAD design, including innovations in biocompatibility, miniaturization, and power management. By examining current research, this review aims to elucidate how LVADs are transforming heart failure treatment and to offer insights into future directions for clinical practice and research.

Outcome Through the Years of Left-Ventricular Assist Devices Therapy for End-Stage Heart Failure: A Review

Heart transplantation remains the gold standard surgical treatment for advanced heart failure. Over time, medical therapies have achieved remarkable outcomes in terms of survival and quality of life, yet their results may be insufficient, even when maximized. The limited availability of organ donors and the selective criteria for heart transplant eligibility have led to a significant rise in the utilization of long-term mechanical circulatory support, including left ventricular assist devices. Patients receiving LVADs often present with multiple comorbidities, constituting a highly vulnerable population. Individuals living with LVADs may experience various long-term complications, such as bleeding, driveline infections, neurological events, and right ventricular dysfunction. Fortunately, the development of increasingly biocompatible LVAD devices in recent years has resulted in a notable reduction in these complications. This review aims to summarize the principal complications encountered by patients with LVADs throughout their treatment and the associated daily management strategies.

Outcomes after noncardiac surgery in patients with left ventricular assist devices: a systematic review

Background

The number of patients living with left ventricular assist devices (LVADs) has gradually increased in the past decade. Non-cardiac surgery (NCS) in patients with LVAD poses a unique situation with its inherent challenges.

Aim

We conducted a comprehensive review to investigate the perioperative complications and mortality associated with emergent or elective NCS in patients with LVAD.

Method

A comprehensive literature search for any papers referring to continuous LVAD patients with NCS. All publications with at least five durable LVAD patients who had NCS were eligible for inclusion.

Result

Twenty articles matching our criteria were found and included in our study. This systematic review included 6,476 LVAD patients who underwent 6,824 NCS. There were 5-3,216 LVAD patients with NCS in each study. The median age was between 39 and 65 years, and most of the patients (78.8%) were male. Thirty-day postoperative mortality ranged from 0% to 60%. Eight studies reported no death within the 30 days of the operation. Common complications include gastrointestinal (GI) bleeding, intracranial bleeding, infection, acute kidney injury (AKI), urinary tract infection (UTI), stroke, sepsis, pneumonia, and VAD exchange. Emergent abdominal surgery had the highest (up to 60%) mortality rate, and vascular and neurological operations had the highest complication rates. Due to the diverse range of patients in each publication and the combination of outcomes presented in various publications, a meta-analysis was not conducted.

Conclusion

In LVAD patients, noncardiac surgery may be performed effectively and safely. LVAD patients who undergo non-cardiac surgery may require more transfusions due to their complex coagulopathies. However, perioperative management of LVAD patients undergoing emergent NCS should be optimized to reduce mortality.

Systematic Review Registration

https://osf.io/fetsb/.

Right heart failure after left ventricular assist device: From mechanisms to treatments

Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure. Depending on the definition, 5-44% of people supported with an LVAD develop right heart failure (RHF), which is associated with worse outcomes. The mechanisms related to RHF include patient, surgical, and hemodynamic factors. Despite significant progress in understanding the roles of these factors and improvements in surgical techniques and LVAD technology, this complication is still a substantial cause of morbidity and mortality among LVAD patients. Additionally, specific medical therapies for this complication still are lacking, leaving cardiac transplantation or supportive management as the only options for LVAD patients who develop RHF. While significant effort has been made to create algorithms aimed at stratifying risk for RHF in patients undergoing LVAD implantation, the predictive value of these algorithms has been limited, especially when attempts at external validation have been undertaken. Perhaps one of the reasons for poor performance in external validation is related to differing definitions of RHF in external cohorts. Additionally, most research in this field has focused on RHF occurring in the early phase (i.e., ≤1 month) post LVAD implantation. However, there is emerging recognition of late-onset RHF (i.e., > 1 month post-surgery) as a significant cause of morbidity and mortality. Late-onset RHF, which likely has a unique physiology and pathogenic mechanisms, remains poorly characterized. In this review of the literature, we will describe the unique right ventricular physiology and changes elicited by LVADs that might cause both early- and late-onset RHF. Finally, we will analyze the currently available treatments for RHF, including mechanical circulatory support options and medical therapies.