European Journal of Heart Failure | 2021
Progressive elimination of adverse events: the key to success for left ventricular assist devices
Abstract
Implantable left ventricular assist devices (LVAD) have undergone significant technological improvements over the past decades. From the bulky, noisy, and short-lived pulsatile devices, such as the HeartMate XVE in the 1990s, to the silent and much more durable continuous-flow devices with first clinical results reported in 20051 and now further developed with the full magnetically levitated centrifugal pumps with implants beginning a decade later.2,3 Given the improved durability of the devices achieved, patients may now live more than 10 years with the same LVAD. Consequently, two main challenges need to be addressed to improve outcomes in this population further: (i) optimal patient selection and timing, (ii) elimination of remaining inherent adverse events. It has been repeatedly documented that heart failure (HF) patients are often referred late for evaluation for LVAD implantation and that this compromises outcomes for patients.4 Many patients undergo implantation in INTERMACS profiles 1 and 2, despite well-documented inferior survival compared to patients in INTERMACS 3–4. Moreover, many patients are never referred for evaluation. In a recent study, patients followed in eight European electrophysiology clinics with either an implantable cardioverter-defibrillator or cardiac resynchronization therapy were screened for the presence of advanced HF and indication for advanced therapies (LVAD or heart transplantation).5 Of patients with New York Heart Association III–IV symptoms and ejection fraction <40%, 26% either had an indication for transplantation or LVAD, without any contraindications, yet strikingly none of the patients had been referred for evaluation for these interventions. This is remarkable, especially as most of the participating electrophysiology clinics were located in hospitals with a fully operational advanced HF programme, including the option to implant LVADs. So clearly, despite recommendations from professional societies,