Implantable left ventricular assist device: indications, eligibility and current outcomes

### Learning objectives 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 …