Article Text
PDF
Statistics from Altmetric.com
Learning objectives
To review the current indications for implantable left ventricular assist device (LVAD).
To understand the specific preimplant considerations for LVAD candidacy.
To review contemporary survival and morbidity outcomes on LVAD support.
Introduction
In patients with heart failure (HF) and left ventricular ejection fraction ≤40%, the annualised rate of progression from stage C to stage D HF is approximately 4.5%.1 In the non-inotrope-dependent patient with advanced HF (AdHF), survival without left ventricular assist device (LVAD) or urgent heart transplant (HTx) is poor, with only 53% alive at 2 years.2 While cardiac transplantation is the treatment of choice for highly selected patients with AdHF, with a median post-transplant survival of 12.5 years,3 the need for donor organs continues to far exceed availability.
In the 1960s the first mechanical pump to replace the failing heart was developed. By the early 1980s, HTx was established as a successful treatment, and it became clear that a method of keeping patients supported until a donor organ could be found was important. In 1984 the first successful electric pulsatile Novacor LVAD was implanted as a bridge to transplantation. The pulsatile HeartMate XVE was granted Food and Drug Administration (FDA) approval for ‘destination therapy’ in 2003. Pulsatile devices were bulky, required a large pocket in the abdomen and had limited durability. The advent of smaller, implantable, continuous-flow devices led to this type of therapy becoming a realistic long-term option for patients with AdHF. Over 2500 LVADs are now implanted annually worldwide.4
This article will cover the indications for LVAD implantation, preoperative considerations and clinical outcomes for continuous-flow LVADs (cfLVADs) used in contemporary practice. Due to the significant reduction in the use of axial flow devices,5 the article will focus on the current third-generation centrifugal devices.
Our review will not detail the management of patients with implantable LVAD; however, we have included practical tips on the initial assessment and management of these patients presenting to the emergency department of a non-LVAD centre (figure 1) and emphasise early liaison with the LVAD centre.
Practical tips on the assessment and initial management of patients with LVAD presenting to the emergency department in a non-LVAD centre. ABCDE principles of resuscitation: airway, breathing, circulation, disability and exposure (Resuscitation Council, UK); CRP, C reactive protein; ENT, ear, nose, throat; FBC, full blood count; GI, gastrointestinal; INR, international normalised ratio; LDH, lactate dehydrogenase; LVAD, left ventricular assist device; RV, right ventricle; TIA, transient ischaemic attack; VAD, ventricular assist device.
(A) HeartMate 3 pump head and driveline: blue arrow, pump head; yellow arrow, outflow graft; red arrow, driveline. (B) HeartMate 3 external peripherals: green arrows, batteries; purple arrow, controller with cables to connect to batteries; red asterisk, driveline attaches to the controller here.
(A) Volume-rendered CT reconstruction of LVAD in situ: blue arrow, pump head in the LV apex; purple arrow: driveline; yellow arrow, outflow graft connected to the ascending aorta. (B) Chest X-ray with LVAD in situ: red arrow, CRT-D system. CRT-D, cardiac resynchronisation therapy-defibrillator; LV, left ventricle; LVAD, left ventricular assist device.
Device types
Two centrifugal cfLVADs dominate the field of implantable mechanical circulatory support (MCS).4 5 The HeartWare (HVAD; Medtronic, Dublin, Ireland) is a centrifugal pump with hybrid levitation of the rotor; the HeartMate 3 (HM3; Abbott, St Paul, Minnesota, USA) has full magnetic levitation. Table 1 lists the principal design features of the HVAD and HM3. As the pumps provide predominantly non-pulsatile blood flow, there is usually no palpable pulse.
Select properties of HeartWare and HeartMate 3 centrifugal flow LVADs
The inflow cannula of the pump is implanted surgically in the apex of the left ventricle (LV). The pump head is above the diaphragm, adjacent to the heart in the pericardial space, with the outflow pipe conventionally connected to the ascending aorta. The driveline connecting the pump to the external controller and power supply is tunnelled through the anterior abdominal wall. The controller and the two batteries are worn over or under the patient’s clothes. Batteries typically last 10–12 hours, and the patient is supplied with multiple batteries and a charger. The patient must be connected to a power source (battery or mains) at all times. This enforces some lifestyle limitations; the patient should not submerse themselves through swimming or bathing, but can shower with appropriate covering. Many patients with the current generation of cfLVADs may return to near normal activities of daily living including exercise, work, travel (including air travel) and (non-contact) sport. The HM3 LVAD with its controller and power pack is shown in figure 2. Figure 3 shows a typical chest X-ray and CT reconstruction of an HM3 device.
Indications for implantable LVAD
Patients with AdHF have New York Heart Association (NYHA) class 3 or 4 symptoms despite optimisation of guideline-recommended medical and device therapy. The latest definition of AdHF by the European Society of Cardiology requires severe symptomatic limitation, objective evidence of cardiac dysfunction, confirmation of functional impairment and adverse clinical trajectory with multiple poor prognostic indicators.6 The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) classification of patients with AdHF was established to further categorise patients in NYHA 3/4, when considering MCS as a treatment option (figure 4).7 Implantable LVADs are indicated for selected patients with AdHF who have poor quality of life and medium-term prognosis. Rapidly reversible causes of HF and significant comorbidity or other life-limiting illnesses need to be excluded before considering LVAD implantation.
Categorisation of patients with HF and 1-year and 2-year survival following implantation of cfLVADs stratified by INTERMACS profile at implant.4 ACC/AHA, American College of Cardiology/American Heart Association; cfLVADs, continuous-flow left ventricular assist devices; ESC, European Society of Cardiology; HF, heart failure; HFmEF, heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; NYHA, New York Heart Association.
Broadly, LVADs may be considered in three circumstances:
In patients listed for HTx unable to maintain end-organ perfusion, LVAD may be used as a ‘bridge to transplantation’ (BTT). In these patients LVAD may improve survival to transplantation.
Selected patients with contraindications to HTx that may be reversed by a period of support on LVAD. For example, secondary pulmonary hypertension and renal function may improve on LVAD support. In these patients LVAD is a ‘bridge to transplant candidacy’ (BTC).
In patients with an absolute and permanent contraindication to HTx, LVAD may be used as long-term therapy. This is often referred to as destination therapy (DT), whereby the patient is supported with the device until the end of life.
Off-loading the LV on an LVAD may facilitate recovery of the failing ventricle,8 and around 5% of LVAD patients have the device explanted for recovery at 5 years.5 For these patients LVAD support is a ‘bridge to recovery’ (BTR). However, it is important to have a clear ‘intention to treat’ strategy (BTT, BTC or DT) prior to implantation, as explant rates for recovery remain low.
These strategies are based on eligibility for HTx at the time of LVAD implantation. It is not uncommon for patients to experience events during LVAD support that may lead to a change in strategy. For example, should a BTT LVAD patient suffer a significant neurological event, the strategy may change to DT. Alternatively, if a BTC patient has either non-resolution of the contraindication to transplant or the development of an absolute contraindication to HTx, the long-term goal becomes DT.
Due to the volume of DT implants in the USA, the majority of LVADs implanted worldwide are in this category. This practice is not replicated in Europe or Asia-Pacific,4 and DT is not currently funded by the National Health Service in the UK.9 In the European Registry for Patients with Mechanical Circulatory Support (2681 patients from 52 hospitals across 18 countries, excluding UK; 2011–2016), the intention at implant was DT in 16%, BTT in 28%, BTR in 2%, BTC for 36% and not specified in the remainder.10
Assessment
The assessment of prognosis in patients with AdHF being considered for LVAD implantation is similar to HTx; we have reviewed these previously.11 Broadly, the process involves an assessment of cardiac function, with objective confirmation of functional limitation and adverse prognostic markers. Box 1 lists the relevant investigations.
Investigations performed during preimplantation assessment
Blood: full blood count, renal function, liver function, thyroid function, iron studies, HbA1c, natriuretic peptide level.
Imaging: echocardiogram, chest X-ray, CT chest, abdomen and pelvis, vascular Doppler study*, ultrasound kidney/liver*, coronary angiography*, cardiac MRI*.
Functional test: 6 min walk test, cardiopulmonary exercise test.
Right heart catheter.
Lung function tests.
Urine: microscopy and culture, albumin to creatinine ratio, toxicology screen.
Microbiology: hepatitis B, hepatitis C, HIV, MRSA screen.
Blood group and tissue typing.
Pacemaker or implantable cardioverter-defibrillator interrogation.
Dental review.
*Performed in select patients where appropriate.
HbA1c, glycosylated haemoglobin; MRSA, methicillin-resistant Staphylococcus aureus.
Good right ventricular (RV) function is essential for effective LVAD support. To achieve mechanical unloading of the LV, flow rates of 4–5 L/min are typically required. As such, the RV must be able to deliver 4–5 L/min of blood to the left heart, while maintaining low central venous pressure to avoid renal and liver dysfunction. Preoperative right heart failure (RHF) is associated with an increased risk of early post-LVAD RHF and is a predictor of poor clinical outcome.12 Table 2 lists the preoperative RV assessment and risk factors for postimplant RHF. No single RV parameter is examined in isolation; RV assessment incorporates clinical findings, imaging features and haemodynamic assessment, with multiple adverse parameters indicative of an increased risk of postimplant RHF. A competent aortic valve is essential to avoid recirculation. Defects in the atrial or ventricular septum (patent foramen ovale, atrial septal or ventricular septal defects) must be identified early and require correction at implantation to avoid the development of a right to left shunt. LVAD cannot be used in patients who have an unrepairable ventricular septal defect.13
Preoperative RV assessment and associated risk factors for postimplant RV failure
Imaging
All patients undergo echocardiography prior to LVAD, to measure LV and RV size and function, exclude any intracardiac shunt and quantify valvular disease. Accurate assessment of RV volume and function is limited by the complex geometry of the RV and dependence on loading conditions. table 2 lists the echocardiographic and haemodynamic measurements of RV function and associated risk factors for postimplantation RHF. A small LV cavity size is also associated with poorer outcomes. LV end diastolic diameter ≤46 mm is predictive of increased mortality postimplantation in patients with restrictive cardiomyopathy.14 CT of the chest, abdomen and pelvis is usually performed to assess the aorta (size, degree of calcification, etc) and peripheral vasculature to aid surgical planning.
Concomitant valvular lesions
Aortic regurgitation (AR) results in recirculation and reduced forward flow. The presence of more than mild AR pre-LVAD requires intervention, generally bioprosthetic valve replacement.13 Pre-existing mild to moderate aortic stenosis (AS) does not impact on LVAD functioning, unless there is concomitant AR. The 2013 International Society for Heart and Lung Transplantation (ISHLT) consensus guidelines recommend considering bioprosthetic aortic valve replacement in severe AS, however regardless of degree of AR.13
Significant mitral stenosis impedes LVAD inflow, and moderate or worse stenosis should be considered for bioprosthetic valve replacement.13 15 LV decompression reduces the severity of mitral regurgitation (MR).16 Severe MR preimplantation does not require additional intervention.13
Significant tricuspid regurgitation (TR) contributes to RHF through RV volume overload, and reduced RV forward flow. Single-centre studies have reported conflicting conclusions on the impact of concomitant tricuspid valve repair on post-LVAD outcomes.17 Recommendations from the ISHLT suggest consideration of surgical repair for moderate or worse TR at the time of implant.13
Patients with mechanical aortic valves require replacement with a bioprosthetic valve due to the high risk of thrombotic complications. Functioning mechanical mitral valve prosthesis does not require routine replacement but requires a higher level of postoperative anticoagulation.15
Concomitant valve intervention at the time of LVAD surgery increases the risk of the operation due to prolonged bypass time and greater incidence of postoperative RHF.18 These additional factors should be accounted for during patient selection.
Haemodynamics
A right heart catheter (RHC) study to measure intracardiac filling pressures and assess RV function is essential prior to LVAD. Optimisation of RV loading may be necessary through the use of diuretics, vasodilatation and inotropes, with haemofiltration in some, prior to a definitive decision on RV suitability. Most LVAD centres aim for a preimplant central venous pressure of <10–12 mm Hg to reduce the likelihood of postoperative RV dysfunction. The RHC also provides a baseline assessment of pulmonary haemodynamics to determine cardiac transplant suitability. In the BTC patient, RHC is generally repeated on LVAD at an interval of 3–6 months to reassess pulmonary pressures and guide suitability and timing of transplant listing.
Ventricular arrhythmias
Off-loading the LV with LVAD support may reduce the frequency of ventricular arrhythmias (VAs). Furthermore, LVAD patients may tolerate VAs without significant haemodynamic compromise because systemic perfusion is maintained by the LVAD, irrespective of heart rhythm. Prolonged VAs may impact on RV function, however with consequent reduction in LV filling compromising LVAD flow.19 In patients with haemodynamic instability predominantly due to VAs (despite conventional pharmacological and catheter treatment), biventricular mechanical support, total artificial heart or HTx may be considered, if clinically appropriate.13
Renal dysfunction
Renal dysfunction in AdHF is multifactorial, secondary to a combination of intrinsic renal disease, reduced renal perfusion and systemic congestion. A preoperative nephrology opinion is essential in patients with impaired renal function to determine whether the renal dysfunction is potentially reversible or secondary to intrinsic disease. Renal function generally improves following LVAD implantation, with a subsequent plateau, followed by a decline.20 In patients with end-stage renal disease (those on dialysis or following kidney transplantation), prognosis following LVAD is particularly poor.21
Hepatic dysfunction
In patients with HF, abnormal liver function is commonly due to congestive hepatopathy with elevated bilirubin, an independent predictor of mortality.22 Patients with euvolaemia with persistently deranged liver function despite improvement in cardiac output following treatment should have a hepatology opinion to exclude irreversible liver disease or an alternative cause sought. In an analysis of 524 patients (all cfLVAD), those with Model of End-Stage Liver Disease eXcluding International Normalized Ratio >14 had lower survival at 1, 3, 6, 12 and 24 months (p<0.001 for all) and an increased risk of early RHF and infection.23
Bleeding diathesis
All LVAD patients require anticoagulation with vitamin K antagonists and an antiplatelet agent to prevent pump thrombosis. Direct acting oral anticoagulants do not currently have a role in this population. Degradation of von Willebrand factor, platelet activation and formation of angiodysplasia predispose LVAD patients to bleeding.24 In patients with bleeding disorders or unable to tolerate anticoagulation, LVAD is not recommended.
Infection
It is not recommended to implant an LVAD in a patient with active bloodstream infection until completion of treatment. In experienced centres, acceptable outcomes may be achieved in carefully selected patients with well-controlled HIV infection.25
Age
There is no absolute age cut-off for LVAD implantation; however, with advancing age comes frailty and other comorbidities impacting outcome. Age >64 years is a predictor of prolonged postimplant hospital stay,26 and older age is associated with increased postimplant mortality.4 INTERMACS reported a significantly inferior 2-year survival for patients ≥70 years (n=590) compared with those <70 years (n=4439): 63% vs 71% (p<0.001), respectively.27 Carefully selected older patients with excellent social support may be considered for DT LVAD implant in experienced centres.
Psychosocial factors
Compliance with medical therapy and follow-up is essential. Previous work has shown that patients with a strong social network, in particular those with a spouse or significant other as primary caregiver, experience better survival following LVAD implant.28 Patients demonstrating non-compliance with medical advice on multiple occasions and those with ongoing substance abuse (including alcohol) are not suitable for LVAD support.13
Outcomes
Quality of life
Multiple studies have reported substantial improvements in functional capacity and quality of life indices following LVAD implant.29 30 Improvements are seen at 3 months and maintained to at least 2 years, with women and older patients taking longer to achieve significant gains.30 31 Postimplant 6 min walk distance has been shown to increase: from baseline of 136 m to 325 m at 12 months and 323 m at 24 months in HM3 LVAD patients32; peak oxygen uptake, however, remains reduced, with values ranging from 11 to 20 mL/kg/min, or 50%–60% predicted.30 33 Current pump technology does not offer optimal support during exercise, predominantly due to fixed pump speed. Targeting other, non-cardiac factors such as anaemia, deconditioning and obesity may aid improvements in exercise capacity.
Survival
With technological advances, survival after cfLVAD continues to improve. In the latest analysis of 6183 patients supported by cfLVAD reported to the ISHLT Mechanically Assisted Circulatory Support (IMACS) registry (35 countries, 2013–2017), 1-year and 4-year survival were 81.1% and 60.5%, respectively.4 In the UK, 532 LVADs were implanted between 2014 and 2018, with 1-year and 3-year survival of 76.5% and 60.5%, respectively.9 In the 2019 INTERMACS report (USA, 13 016 FDA-approved cfLVADs, 2014−2018), the 1-year survival was significantly higher for cfLVADs with full magnetic levitation than hybrid levitation (87% vs 79%, p<0.001).5 Neurological dysfunction (19%), multiorgan failure (18%) and RHF (10%) remain the predominant causes of death.4
Although short-term survival on the current generation of LVADs is now approaching that following HTx (1-year survival 86.3%), longer-term post-transplant survival remains superior.3 Around 50% of patients undergoing HTx are supported on MCS (LVAD in the majority), with conflicting data on the impact of LVAD support on post-transplant survival.3 34 In the UK, the rates of transplant following LVAD are low at 6% and 18% at 1 year and 3 years, respectively.9
Patient selection remains crucial to improving survival. Nearly a third of patients undergoing durable LVAD implant in INTERMACS profile 1 succumb in the first 2 years.4 Patients in profiles 1–2 should be stabilised (and may require temporary MCS, if appropriate) prior to reassessment. Figure 4 shows the survival stratified by INTERMACS profile of patients supported on cfLVADs.
Morbidity
Despite significant improvements in post-LVAD survival, patients may experience considerable morbidity resulting in recurrent hospitalisations. In a US study of 2510 LVAD recipients, 31% were rehospitalised within 30 days; infection, bleeding and device-related issues accounted for over 75% of these.35 The Society of Thoracic Surgeons’ (STS) annual report reported 218 readmissions per 100 patients at 12 months.5 Table 3 lists the major adverse events reported in the pivotal clinical trials for HVAD and HM3 and the recent IMACS registry report.
Adverse event rates* from pivotal centrifugal flow LVAD trials and IMACS registry
Infection
Infection accounts for the majority of the adverse events reported following LVAD implant. Of patients reported to IMACS registry (10 171 patients on MCS, 2013–2015), 37% had ≥1 episode of infection, with the majority reported in the first 3 months.36 Two-thirds of these were non-VAD infections (eg, pneumonia, urinary tract infection), with VAD-specific infections the second largest group. Driveline infections accounted for 82.3% of VAD-specific infections. Staphylococcus aureus and Pseudomonas aeruginosa are responsible for the majority of driveline infections.37
Occurrence of infection impacts adversely on LVAD survival: 2-year survival 59% vs 74.8% in those with and without infection, respectively.36 This morbidity appears to be driven primarily by infections distant to the pump or its components as those with driveline infection have similar survival to those without.38
Bleeding
Mucosal bleeding primarily manifests as gastrointestinal bleeding (GIB). The development of increased nasal hypervascularity also predisposes these patients to epistaxis. The incidence of GIB is between 15% and 25% in the first year.5 39 Postimplant RHF and older age are important risk factors for GIB.40 41 GIB is a frequent cause of rehospitalisation,35 and although associated with considerable morbidity does not impact on survival.39 The pathophysiology of GIB is complex and the direct risk of antiplatelet and anticoagulant therapy does not fully account for this. Additional mechanisms include the development of arteriovenous malformations, impaired platelet aggregation and acquired von Willebrand syndrome.41–43 Endoscopy of the gastrointestinal tract is the mainstay of investigation, and treatment generally involves proton pump inhibitors, blood transfusion and (temporary) discontinuation of anticoagulation.
Stroke
Stroke may be ischaemic or haemorrhagic, with incidence varying from 10% to 15%.29 32 44 Hypertension (mean arterial pressure >90 mm Hg) is a major predisposing factor44 and women are more commonly affected.45 Stroke is associated with up to a sixfold increased risk of in-hospital mortality.45 Significant debility following stroke may make a patient ineligible for transplantation. The mechanism for ischaemic stroke includes embolisation of thrombus deposited in the pump, inflow or outflow graft, or the aortic valve. Treatment with systemic thrombolysis should be carefully considered in view of the substantive risk of haemorrhagic transformation. The risk of worsening haemorrhagic stroke or potential for haemorrhagic transformation of ischaemic stroke necessitates cessation of antithrombotics, and this has to be balanced against the consequent risk of thrombosis.
Right heart failure
RHF following LVAD has been defined in several ways depending on the type of RV support (inotropes, pulmonary vasodilators, RVAD) and its duration.32 46 47 The incidence of reported RHF therefore varies considerably; the STS INTERMACS registry reports an incidence of 33% at 1 year.5 Risk scores for predicting RHF have limited utility in clinical practice. These scoring systems incorporate rapidly changing parameters such as renal function and bilirubin plus haemodynamic and echocardiographic criteria that vary with loading conditions.48 What is clear however is that patients in lower INTERMACS profiles, requiring multiple inotropes or temporary RV support, those on renal replacement therapy, and those requiring mechanical ventilation are more likely to develop RHF following LVAD.46 48
RHF leads to kidney, liver and gut congestion with consequent derangement in clotting, metabolism and drug absorption. Management of RHF involves optimisation of preload, use of inotropes and pulmonary vasodilators. In select patients mechanical RV support may be required. RHF is associated with increased intensive care unit stay and both early and late mortality; these patients may die due to multiorgan failure and sepsis.46 In-hospital mortality in those requiring unplanned RV mechanical support following LVAD implant is high; 74% in those failing to wean from RV support did not survive to discharge in a recent series.49 Furthermore survival remains poor in patients who develop late RHF, with inferior outcomes even after transplantation.50
De novo Aortic regurgitation
The LVAD decompresses the LV and reduces LV end diastolic pressure. The outflow is usually directed into the ascending aorta, and pressure in the aortic root may therefore be higher than in the LV cavity. Consequently, the aortic valve may not open with every cardiac cycle, and in some patients the aortic valve remains closed throughout.
Development of significant de novo AR results in wasteful recirculation and adverse haemodynamics. De novo AR is a progressive phenomenon with female sex, older age, preimplant mild or greater AR, and a closed aortic valve associated with a greater risk of progression.51 52 In a recent analysis of the INTERMACS registry, 15% of patients developed moderate to severe AR at 2 years.51 Significant AR was associated with higher rates of rehospitalisation (32.1% vs 26.6%, respectively, at 2 years; p=0.015) and mortality (77.2% vs 71.4%, respectively, at 2 years; p=0.005), conditional on survival to 1 year.51
Postoperatively, optimisation of LVAD speed and blood pressure may reduce the clinical impact of AR.53 Surgical treatment should be individualised with options including replacement with a bioprosthetic valve or aortic valve oversew.
Implantable cfLVADs to support the right ventricle
The RV is thinner and more trabeculated than the LV. It is designed to be a high-volume, low-pressure pump. In select patients with predominantly severe RV dysfunction and preserved LV, isolated implantable right ventricular assist device (RVAD) has been described, with the off-label implantation of both the HM3 and the HVAD, with modifications, in the RV or right atrium.54 The RVAD has to be run at lower speeds to prevent ‘suck down’ and is more prone to thrombosis. There is no implantable device specifically designed for this purpose available commercially at present.
Few centres have also supported patients with biventricular failure with implantable cfLVADs (both HVAD and HM3) in biventricular configuration (BiVADs). Survival in BiVAD configuration ranges from 50% to 60% at 1 year, although more encouraging results have been reported from a recent Australian single-centre series.54 55 Practically, the requirement for two controllers and a double set of batteries makes this a cumbersome configuration for the patient.
Future perspectives
Significant gains have been made in LVAD technology. Contemporary pumps are smaller, with improved haemocompatibility and negligible mechanical failure. The driveline remains the Achilles heel of current devices. Innovations in battery technology and transcutaneous power transfer will allow the future generation of LVADs to be fully implantable. Developments in devices tailored specifically for RV support and improved total artificial heart designs will also permit access to these technologies with improved outcomes for those requiring biventricular support.
Conclusion
LVADs are an established treatment option for carefully selected patients with AdHF, with superior survival to those managed medically. MCS technology has rapidly advanced over the last decade, with short-term survival on contemporary LVADs now similar to that after HTx. Patients supported on LVADs experience improvement in their quality of life and functional capacity. However, a high frequency of adverse events and cost remain an impediment to adopting this treatment in the wider HF population. In order to be an acceptable and cost-effective alternative to HTx, further reduction in LVAD-associated morbidity is required.
Key messages
Continuous-flow left ventricular assist devices (LVADs) are an established treatment for carefully selected patients with advanced heart failure, with superior survival to those managed on medical therapy alone.
The majority of patients supported on LVAD have significantly improved quality of life and increased functional status following implantation.
Although 2-year survival following LVAD implantation is now similar to that following cardiac transplantation, medium-term to longer-term survival remains superior in those undergoing transplantation.
Infection, bleeding and neurological events remain the predominant adverse events after implant.
Reduction in readmissions and adverse event rates is necessary for LVADs to become cost-effective and a viable longer-term alternative to cardiac transplantation.
CME credits for Education in Heart
Education in Heart articles are accredited for CME by various providers. To answer the accompanying multiple choice questions (MCQs) and obtain your credits, click on the ‘Take the Test’ link on the online version of the article. The MCQs are hosted on BMJ Learning. All users must complete a one-time registration on BMJ Learning and subsequently log in on every visit using their username and password to access modules and their CME record. Accreditation is only valid for 2 years from the date of publication. Printable CME certificates are available to users that achieve the minimum pass mark.
Ethics statements
Patient consent for publication
References
Footnotes
Contributors All authors were involved in planning, writing and review of this paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Commissioned; externally peer reviewed.
Author note References which include a * are considered to be key references.