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profile 56, when they have high-risk characteristics. Patients with no irreversible end-organ failure other than cardiac, recovering from INTERMACS level 1 while on short-term MCS, may also qualify for long-term MCS (Figure 4).376,378,383,395402 The characteristics of patients potentially eligible for implantation of an LVAD are reported in Table 16. The details of the devices and studies on long-term MCS are summarized in Supplementary Table 15. Current 2-year survival rates in patients receiving the latest continuous-flow LVADs are comparable to those after heart transplantation, although adverse events negatively affect QOL. Among patients with continuous flow LVADs, actuarial survival was reported of 80% at 1 year and 70% at 2 years.403,404 Two-year survival was 84.5% and survival free of disabling stroke or need of reoperation for LVAD malfunction was 76.9% with a centrifugal-flow LVAD in MOMENTUM 3.405 The fully magnetically levitated centrifugal-flow LVAD has significantly reduced pump thrombosis. In MOMENTUM 3, the need for reoperation to replace a malfunctioning device was 2.3% per 24 months, with only 0.6% per 24 months risk of pump replacement because of pump thrombosis. Stroke (namely, disabling stroke), major bleeding, and gastrointestinal haemorrhage were also lower in the centrifugal-flow pump group than in the axial-flow pump group. However, the incidence of all bleeding events, thromboembolism and driveline infection remained similar to that with older devices.402

Data on fully magnetically centrifugal-flow LVAD use in real-world studies with the 2-year outcomes from the ELEVATE registry showed an overall survival of 74.5%, with gastrointestinal bleeding in 9.7%, stroke in 10.2%, and pump thrombosis in 1.5% of patients.406 According to the IMACS Registry, a new composite endpoint including QOL and adverse events beyond survival was proposed to help in guiding decision making. In this sense ‘living well at one year’ defined as freedom from death, stroke, bleeding requiring operation, RV assist device, pump replacement, or device-related infection within the first year, was 56.8% after isolated, centrifugal flow- LVAD.383 Although now outdated, REMATCH was the only RCT comparing an LVAD as DT with OMT in patients with advanced HF, NYHA class IV and a contraindication to transplantation. REMATCH showed lower all-cause mortality with LVAD therapy when compared with medical treatment (primary endpoint). However, there were high mortality rates at 2 years in both arms.378 Other studies were not randomized (INTrEPID, ROADMAP)396,407,408 or compared different devices (ADVANCE, ENDURANCE, MOMENTUM 3).399,402,409 The two strategies of early LVAD implantation vs. medical treatment with LVAD implantation only after serious deterioration of the patient’s condition are currently being compared in a

Table 15 Terms describing various indications for mechanical circulatory support

Bridge to decision (BTD)/ Bridge to bridge (BTB) Use of short-term MCS (ECMO or Impella) in patients with cardiogenic shock until haemodynamics and end-organ

perfusion are stabilized, contraindications for long-term MCS are excluded (brain damage after resuscitation) and additional therapeutic options including long-term VAD therapy or heart transplant can be evaluated.

Bridge to candidacy (BTC) Use of MCS (usually LVAD) to improve end-organ function and/or to make an ineligible patient eligible for heart

transplantation.

Bridge to transplantation (BTT) Use of MCS (LVAD, BiVAD or TAH) to keep a patient alive who is otherwise at high risk of death before transplantation until a donor organ becomes available. Bridge to recovery (BTR) Use of MCS (short-term or long-term) to keep a patient alive until cardiac function recovers sufficiently to remove

MCS.

Destination therapy (DT) Long-term use of MCS (LVAD) as an alternative to transplantation in patients with end-stage HF ineligible for transplantation. BiVAD = biventricular assist device; ECMO = extracorporeal membrane oxygenation; HF = heart failure; LVAD = left ventricular assist device; MCS = mechanical circulatory support; TAH = total artificial heart; VAD = ventricular assist device. ESC 2021

Table 16 Patients potentially eligible for implantation of a left ventricular assist device

Patients with persistence of severe symptoms despite optimal medical and device therapy, without severe right ventricular dysfunction and/or severe TR, with a stable psychosocial background and absence of major contraindications*, and who have at least one of the following:  LVEF <25% and unable to exercise for HF or, if able to perform cardi-

opulmonary exercise testing, with peak VO2 <12 mL/kg/min and/or <50% predicted value.  >_3 HF hospitalizations in previous 12 months without an obvious pre-

cipitating cause.  Dependence on i.v. inotropic therapy or temporary MCS.  Progressive end-organ dysfunction (worsening renal and/or hepatic

function, type II pulmonary hypertension, cardiac cachexia) due to reduced perfusion and not to inadequately low ventricular filling pressure (PCWP >_20 mmHg and SBP <_90 mmHg or cardiac index <_2 L/min/m2). HF = heart failure; i.v. = intravenous; LVAD = left ventricular assist device; LVEF = left ventricular ejection fraction; MCS = mechanical circulatory support; PCWP = pulmonary capillary wedge pressure; SBP = systolic blood pressure; TR = tricuspid regurgitation; VO2 = oxygen consumption. *Stable psychosocial background includes demonstrated understanding of the technology and patient living in the same household with a caregiver that will help the patient (i.e. living alone and poor psychosocial background is LVAD contraindication). Major contraindications include contraindication to long-term oral anticoagulation, infection, severe renal dysfunction, ventricular arrhythmias. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026