Left ventricular device as destination therapy: are we there yet?

PURPOSE OF REVIEW: Mechanical circulatory assistance is evolving from bridge-to-transplant to destination therapy for end-stage heart failure patients. Recent studies document the evolution in outcomes following destination therapy achieved subsequent to the landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial, as well as the outcomes of second-generation left ventricular assist devices (LVADs). RECENT FINDINGS: Post-Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure destination therapy patients receiving first-generation pulsatile flow devices have benefited from some improvement in 2-year outcomes and some reduction in the incidence of adverse events including device failure and sepsis. Despite these improvements, survival at 2 years remains poor and adverse events continue to portend significant morbidity and mortality. Second-generation continuous axial flow devices have demonstrated superior device durability and reliability as well as significant reductions in the incidence of sepsis and device-related infections in bridge-to-transplant patients. SUMMARY: Second-generation axial flow devices have significantly improved the adverse-event profile of LVAD therapy and are anticipated to offer substantial device longevity. Destination therapy is clearly an option for some patients with end-stage heart failure. As devices and experience evolve, outcomes will improve, which begs the question of whether these devices will have a role in the treatment of patients not as ill as those in the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial.