The expanding role of ventricular assist devices in the management of end-stage heart failure

Rapid advances in the medical treatment of congestive cardiac failure have improved both the quality of life and life expectancy. However end-stage heart failure poses immense challenges to the clinician. Cardiac transplantation has been the mainstay of treatment for a small group of patients who can no longer be managed effectively with therapeutic agents. Unfortunately the limited donor pool restricts the number of patients who can be offered this treatment. Mechanical devices for circulatory support have been proposed to bridge patients to a successful transplant, and more ambitiously have been proposed as an alternative to transplantation. There has been a profusion of new devices using different technologies, but all remain limited by the biological-mechanical interface. There are significant economic considerations if the technology is to be available to everyone with heart failure. This article reviews the history of ventricular support, indications, outcome data and practical advice on management of the patient with the VAD from the pre-operative phase to discharge into the community.