Mechanical Circulatory Support for Advanced Heart Failure
Patients and Technology in Evolution
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After nearly 50 years of clinical development, durable mechanical circulatory support (MCS) devices are widely available for patients with advanced heart failure. The field of circulatory support has matured dramatically in recent years, thanks to the advent of smaller, rotary pumps. The resulting transition away from older pulsatile devices has been swift. Accelerated use of continuous-flow left ventricular assist devices (LVADs) for long-term support has changed the face of advanced heart failure care. MCS candidate selection, risk stratification, and management strategies are evolving in tandem with new pump technology, producing a shift in the profiles of patients being considered for MCS. Timely referral for MCS evaluation and appropriate implantation now depends on familiarity with recent advances in pump design and clinical outcomes. This review, the first in a series on Advances in Mechanical Circulatory Support, will focus on durable intracorporeal LVADs used in adults with advanced heart failure, and highlight the evolution in both patients and technology.
History of Mechanical Circulation
The modern era of cardiac surgery began in 1953 with the first clinical use of cardiopulmonary bypass, allowing increasingly complex operations and laying the foundation for circulatory assist devices.1 Shortly after its invention, the heart-lung machine began to be used to support patients with postcardiotomy cardiogenic shock to facilitate recovery after failed operations. By the 1960s, simple cardiac assist devices began to replace cardiopulmonary bypass for the treatment of postcardiotomy shock (Figure 1). The first clinical use of an implantable artificial ventricle was reported by Liotta et al2 in 1963. This primitive ventricular assist device (VAD) consisted of a pneumatically driven, tubular displacement pump with a valved conduit connecting the left atrium to the descending thoracic aorta. The pump provided partial left ventricular bypass for 4 days after postoperative cardiac arrest before the patient died of multiorgan failure. Inspired by …