Mechanical circulatory support

Abstract

Abstract Mechanical circulatory support (MCS) has evolved dramatically over the last 50 years. Circulatory pumps are routinely being used to treat the spectrum of presentations ranging from cardiogenic shock (short-term, for acute haemodynamic restoration) advanced heart failure (long-term, to improve quality and duration of life). Short-term pumps typically are used to assist the circulation in cardiogenic shock or as a back-up in high-risk cardiac interventions. The evidence base for such application is in evolution and most application algorithms are still dependent on individual centre-based criteria. Left and right ventricular mechanical performance, lung function, and systemic perfusion are the most important clinical factors in the decision tree. For durable MCS, left ventricular assist systems (LVAS) are the mainstay for use. Implantable, continuous flow LVAS are effective and reliable in leading to improved survival and quality of life but do require monitoring for complications related to haemocompatibility (pump thrombosis, strokes and non-surgical bleeding), heart failure and infection. A considerable body of evidence from adequately powered, randomized and observational clinical studies support the use of current LVAS, particularly the HeartMate 3 pump. The primary indication for proceeding with LVAS is in advanced HF refractory to routine medical therapy, irrespective of whether the patient is a candidate for transplantation or not. In selected patients LV recovery may even allow for explant of the LVAS without recurrence of advanced HF, however this is uncommon. Patients with biventricular failure may be treated with a total artificial heart and the ongoing developments in this field are reviewed.