Current and Future Challenges in Mechanical Circulatory Support

Abstract

The field of left ventricular assist devices (LVADs) has transitioned from older, bulkier devices which provided short-term life prolongation in severe heart failure, to newer generation continuous-flow devices which are small in profile, with fewer moving parts and greater durability. These devices have provided meaningful life prolongation in a manner similar to heart transplantation even for those deemed ineligible for such an approach, a paradigm referred to as destination therapy. a) Clinical confidence in the therapy: Most practitioners do not recognize that the latest generation HeartMate 3 LVAD, provides 80% 2-year survival, dramatically improves quality of life and is now cost-effective even as destination therapy. Thus, we need to ensure that clinicians are provided the knowledge to communicate effectively with their peers and patients. In this regard, development of individualized risk scores may be necessary. b) Timely referral for LVAD therapy: Late referral of patients with symptoms of advanced heart failure remains a critical challenge. A simple rule of 3 should be used and this includes a) repetitive hospitalizations for heart failure, b) staircase diuretic requirements over time (e.g., an increase of oral loop diuretic therapy by 50% in the preceding 6 months), and c) intolerance to neurohormonal therapy with onset of cardio-renal perturbation. Those with moderate-severe secondary mitral regurgitation ineligible for a percutaneous mitral valve transcatheter edge to edge repair (or those implanted with a MitraClip who remain ill without improvement in heart failure) and non-responders to cardiac resynchronization therapy should also be referred for management at centers specializing in advanced heart failure therapeutics. c) Need for continued innovation in LVAD therapy: Newer technology that can promote recovery, provide freedom from external cables, use biocompatible surfaces to reduce need for anticoagulation, and physiologically responsive to demands of an active lifestyle is needed. In summary, the future of LVAD therapy is bright but we must not only pursue innovative engineering but also focus on clinical implementation to provide such therapy to advanced heart failure patients in a timely manner. The field of left ventricular assist devices (LVADs) has transitioned from older, bulkier devices which provided short-term life prolongation in severe heart failure, to newer generation continuous-flow devices which are small in profile, with fewer moving parts and greater durability. These devices have provided meaningful life prolongation in a manner similar to heart transplantation even for those deemed ineligible for such an approach, a paradigm referred to as destination therapy. a) Clinical confidence in the therapy: Most practitioners do not recognize that the latest generation HeartMate 3 LVAD, provides 80% 2-year survival, dramatically improves quality of life and is now cost-effective even as destination therapy. Thus, we need to ensure that clinicians are provided the knowledge to communicate effectively with their peers and patients. In this regard, development of individualized risk scores may be necessary. b) Timely referral for LVAD therapy: Late referral of patients with symptoms of advanced heart failure remains a critical challenge. A simple rule of 3 should be used and this includes a) repetitive hospitalizations for heart failure, b) staircase diuretic requirements over time (e.g., an increase of oral loop diuretic therapy by 50% in the preceding 6 months), and c) intolerance to neurohormonal therapy with onset of cardio-renal perturbation. Those with moderate-severe secondary mitral regurgitation ineligible for a percutaneous mitral valve transcatheter edge to edge repair (or those implanted with a MitraClip who remain ill without improvement in heart failure) and non-responders to cardiac resynchronization therapy should also be referred for management at centers specializing in advanced heart failure therapeutics. c) Need for continued innovation in LVAD therapy: Newer technology that can promote recovery, provide freedom from external cables, use biocompatible surfaces to reduce need for anticoagulation, and physiologically responsive to demands of an active lifestyle is needed. In summary, the future of LVAD therapy is bright but we must not only pursue innovative engineering but also focus on clinical implementation to provide such therapy to advanced heart failure patients in a timely manner.