Introduction    About 250,000 Americans have end-stage heart failure, meaning they cannot carry out any physical activities without discomfort (dyspnea or angina) and are potentially eligible for advanced therapy such as heart transplantation. Less than 1% of patients, however, will receive a heart transplant. The left ventricular assist device (LVAD) was initially designed as an implanted mechanical circulatory support (MCS) to extend the life of patients awaiting heart transplants (“bridge-to-transplantation” (BTT)). In 2002, the FDA approved the LVAD not only as BTT, but also as “destination therapy” (DT) where the patient would keep the device for life, with no expectation of heart transplantation. Advance care planning and serious illness discussions are recommended as part of the informed consent process of LVAD consideration.  This Fast Fact provides a primer on LVADs to palliative care providers and other clinicians who care for patients with advance heart failure.  See Fast Facts #269 and Fast Fact #410 for additional information. 

The technology (1)     Rapid growth in the types of MCS has occurred, including the development of the total artificial heart (see Fast Fact #296), intra-aortic balloon pump, Impella device, right ventricular assist, and biventricular support.  Basically, an LVAD involves surgical implantation by a cardiothoracic surgeon (usually done a high volume, tertiary care medical centers) of a pump to support cardiac output. Most often, this includes a conduit implanted in the left ventricle, and another into the aorta. Blood is pulled from the left ventricle, and mechanically moved into the aorta, increasing cardiac output and reducing heart failure symptoms. First generation LVADs did this with a pumping motion (pulsatile flow), but newer generation LVADs move blood continuously and utilize magnetic levitation and centrifugal flow (e.g., HeartMate 3) to reduce complication risks from pump thrombosis, strokes, and bleeding.  A third conduit (the driveline) passes from the pump through the abdominal wall and attaches to the device’s battery and control system. This is of particular importance as serious life-threatening infections can result via the driveline. Patients go home with their LVADs using a wearable battery system.  

Eligibility (2)  Typically advance heart failure specialists, cardiologists, and cardiothoracic specialists identify patients who may be eligible for destination LVAD therapy.  In general, a patient needs to have severe heart failure (New York Heart Association or NYHA class 3 or 4), refractory symptoms despite optimal medical management, a severely low ejection fraction (e.g., <30%), inotrope dependence, very low peak oxygen consumption (<12 ml/kg/min), and sufficient body surface area to accommodate the LVAD. Advanced heart failure teams carefully assess the patient’s overall health, organ function, and comorbidities and utilize multidisciplinary teams to make eligibility determinations.  Illnesses like metastatic cancer, severe peripheral vascular disease, and cirrhosis may preclude eligibility. 

Outcomes and considerations 

• In randomized studies, LVADs have shown significant mortality benefits. The newer generation, centrifugal flow LVADs have shown 5-year Kaplan-Meier survival rates of 58.4% compared with 29.7% for axial-flow devices (3).  In fact patients less than 50 who received HeartMate3 had a 76% survival rate at 5 years which parallels the outcomes from heart transplant (3,4).
• Poorer survival is predicted by poor nutritional status (hypoalbuminemia), coagulopathy, baseline renal dysfunction, right heart dysfunction, and care at a less experienced MCS center (5,6).
• The wide majority of recipient experience marked improvements in their NYHA functional class (e.g, go from class IV to class I); health-related quality of life typically improves by more than 178% (7,8). Readmission rates reduce significantly as well (9).
• While markedly improved, newer generation LVAD recipients remain at risk for complications such as recurrent gastrointestinal bleeding, infections, hospitalizations, and right heart failure (1,10,11).
• Perioperative mortality has improved dramatically (often less than 10%) with improved patient selection and technology; however, palliative medicine providers and ICU staff often see MCS patients at their worst when critically ill or with a protracted, complicated recovery. This can be a source of moral distress. Nevertheless, many eventually go on to perform all activities of daily living and have improved quality of life.
• MCS require a high degree of ongoing device care including daily self-care (e.g. controller self-tests, changing and maintaining power sources, and driveline exit site dressing changes), safety precautions (e.g. no emersion in water, showering with a shower kit, precautions while driving and traveling, need for a trained caregiver), and the ability to troubleshoot emergent MCS-related malfunction. Due to this, social stability and patient/family responsibility are key selection criteria when considering MCS implantation.

Discontinuing MCS   MCS may be implanted as BTT, but later become DT if patients are no longer transplant candidates. In the rare instance of myocardial recovery, some devices can be explanted. More often, MCS is removed at cardiac transplantation or, in the case of DT, when severe complications arise (such as pump thrombosis, mechanical pump failure etc). Practical aspects of discontinuing an LVAD in a dying patient are discussed in Fast Fact #269. 

Advance care planning   See Fast Fact #410 for more information. MCS is a surgical therapy which can significantly prolong life and improve function in appropriately selected patients, but it can also be associated with significant morbidity and treatment burden. Discussions with patients and surrogates to clarify prognosis, goals, and endpoints for MCS therapy should take place before implantation. These discussions should address the quality of life below which a patient would no longer want to continue MCS, and would want to initiate comfort focused only.  

References 

1. Racharla, L., Sidhu, K. & Vidula, H. New Advances in Medical Management of Left Ventricular Assist Devices Recipients. Curr Treat Options Cardio Med 2024; 26:299–306.
2. Masarone D, Houston B, Falco L, et al. How to Select Patients for Left Ventricular Assist Devices? A Guide for Clinical Practice. J Clin Med. 2023 Aug 10;12(16):5216.
3. Mehra MR, Goldstein DJ, Cleveland JC, et al. Five-year outcomes in patients with fully magnetically levitated vs axial-flow left ventricular assist devices in the MOMENTUM 3 randomized trial. JAMA. 2022;328(12):1233.
4. Khush KK, Cherikh WS, Chambers DC, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-sixth adult heart transplantation report – 2019; focus theme: Donor and recipient size match. J Heart Lung Transplant Off Publ Int Soc Heart Transplant. 2019;38(10):1056–66.
5. Slaughter MS, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009; 361:2241-2251.
6. Kirklin JK, et al. Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant. 2013; 32:141-56.
7. Cowger J, et al. Predicting survival in patients receiving continuous flow left ventricular assist devices: The HeartMate II Risk Score. J Am Coll Cardiol. 2013; 61: 313-21. Rogers JG, et al. Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients. J Am Coll Cardiol. 2010; 55:1826-1834.
8. Rogers JG, et al. Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients. J Am Coll Cardiol. 2010; 55:1826-1834.
9. Hasin T, et al. Readmissions after implantation of axial flow left ventricular assist device. J Am Coll Cardiol. 2013; 61:153-63.
10. Prario M, Sutari N, Gallandt A, et al.  The burden of readmissions in the first with an LVAD: predictors associated with quality of life outcomes.  The Journal of Heart and Lung Transplantation 2021; 40(4):S434.
11. Lemor A, Michaels A, Al-Darzi W, Hernandez GA, et al. National landscape of hospitalizations in patients with left ventricular assist device. ASAIO J. 2020;66(10):1087–94. 

Author Affiliations: Mayo Clinic, Rochester, MN (KMS); University of Colorado-Denver, Aurora, CO (DDM), University of Pittsburgh Medical Center, Pittsburgh, PA (HF); Health East Care System, St Paul, MN (SH).
Version History: Originally written by Heather Ferris MD and Susan Hunt MD, and published August 2008. 2nd Edition in June 2009. Heavily rewritten to reflect new data and republished in May 2013; copy-edited again in July 2015; reviewed and updated again in June 2025.
Conflicts of Interest: None to report.