Permanent circulatory support in refractory chronic heart failure

The prevalence of heart failure is increasing and the prognosis in the terminal phase is dismal. The gold-standard therapy in end-stage heart failure remains cardiac transplantation at the present time, but there is a great excess of eligible candidates compared with the number of donor organs, so alternative strategies are needed. The usefulness of left ventricular assist device as destination therapy is one of the objectives pursued since the first devices began to be developed; the technological and design improvements in ventricular assist devices in the last 20 years has allowed its use in these patients. Data from multicenter trials and registries have demonstrated an improvement in survival and quality of life in patients with advanced heart failure when they are implanted as outpatient long-term support. The REMATCH (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure) trial entailed the scientific confirmation of that benefit and other later studies support it. The present article discusses many aspects of ventricular assistance as destination therapy: lessons learned with the different devices along the years, the complications and morbidity associated with them or the specific designed clinical trials. There is a special emphasis on destination therapy patient's selection and on specific risk scores for ventricular assistance; other options for long-term support less used as the total artificial heart or implantable micro-pumps are also briefly considered.