Left ventricular assist devices: evolving devices and indications for use in ischemic heart disease

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Abstract
The mortality with end-stage heart failure is extremely high, especially when patients become refractory to conventional medical therapy and require frequent hospitalization. Ischemic heart disease remains the primary cause of advanced heart failure. Mechanical pumps or devices have been developed called ventricular assist devices and are being used to support an increasing number of patients with refractory heart failure. The use of ventricular assist devices has evolved from initially only support of patients unable to be weaned from a heart–lung machine after cardiac surgery to use now as a bridge to a heart transplant, including patients with acute myocardial infarction and shock and severe pulmonary hypertension. More recently, they have been proven as a definitive alternative for patients not eligible for heart transplantation. There are new devices being examined in clinical trials, including a change from pusher-plate to devices with axial flow technology that are much smaller and easier to implant. Outcomes with their use are improving rapidly as the devices become more reliable and more is learned about the importance of candidate selection. This review describes current indications for the use of these devices, the types of pumps now available, criteria for initiating ventricular assist device support, complications of their use, and new applications such as a platform for stem cell therapy for treatment of end-stage heart failure.