LVAD as Bridge to Transplant: Candidacy, Devices, Referral

A left ventricular assist device (LVAD) is an implanted pump that takes over the work of a failing left ventricle. Used as a bridge to transplant, it supports a patient until a donor heart arrives; it can also rebuild a patient too sick to be listed into a candidate, or serve as permanent destination therapy. Candidacy depends above all on the right heart and on early referral.

Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, implants LVADs and performs heart transplants, including for foreign nationals. For foreign nationals, whose wait for a donor heart has a median of about a year, the LVAD is often what makes a transplant achievable at all. This article covers where the device sits in the heart failure treatment ladder, the three ways it is used, the devices and their prices as he described them, the candidacy criteria, and what referring doctors should do and send. For the overall pathway, see the complete guide to heart transplant in India for foreign nationals.

The heart failure treatment ladder

Advanced heart failure is treated in steps, and the LVAD sits near the top.

1. Medical therapy. Medicines are the primary therapy. In Dr. Purkayastha's practice they remain the mainstay until the ejection fraction, the share of blood the left ventricle ejects with each beat, falls below about 20%.
2. An implantable cardioverter defibrillator (ICD). At around that point he considers an ICD, a device that detects dangerous heart rhythms and shocks the heart back into a normal rhythm. Current ESC guidelines recommend a primary-prevention ICD for most patients whose ejection fraction stays at 35% or below despite at least three months of optimal medical therapy.
3. Mechanical circulatory support. As the heart enlarges, the patient becomes increasingly breathless and reaches New York Heart Association (NYHA) class IV, breathlessness at rest, or an INTERMACS profile of 3 to 4 (INTERMACS profiles grade advanced heart failure from 1, critical cardiogenic shock, to 7, advanced but stable symptoms). At this stage the patient needs either temporary veno-arterial support while a decision is made, or, if the right heart is reasonably well, a durable LVAD straight away.
4. Heart transplant. The definitive treatment for end-stage heart failure, reached directly or after a period on an LVAD.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the temporary support used at step 3: a circuit that drains blood from a vein, oxygenates it and pumps it back into an artery, supporting both heart and lungs for days to weeks. Dr. Purkayastha moves a patient straight to an LVAD when a right heart catheterisation, or a very good echocardiographic assessment of the right heart, shows that the right ventricle can cope.

What an LVAD is and how patients live with one

An LVAD is a small pump implanted inside the body and connected to the left ventricle. It is driven by a small controller worn by the patient throughout the day and powered by two battery packs, one on each side, which Dr. Purkayastha describes as giving about a day of power. The batteries are recharged while the patient sleeps, rests or is at home, so that the device never runs out of power. Modern batteries are lithium-ion and much lighter than earlier ones.

The only life restriction he cites is swimming and other underwater activities. Apart from that, people with an LVAD have gone back to the gym and some have run half marathons. The current devices are compact, roughly the size of a palm, and far less restrictive than the first-generation pumps.

LVAD as a bridge to transplant, and two other uses

Bridge to transplant

A bridge to transplant is an LVAD implanted in a patient already accepted for transplant who cannot get a heart in time. Dr. Purkayastha cited exactly the situation of a foreign patient in India who has been worked up and listed but cannot get an organ: the patient goes onto an LVAD, with transplant still the definitive answer. A patient on an LVAD who wanted a transplant and did not get one is, in his words, almost unreal, because the device allows the patient to wait for years.

Bridge to candidacy

A bridge to candidacy is support for a patient who is too sick to be listed. Such a patient may not survive the next 24 hours, so the immediate goal is simply to save them that day, on a ventricular assist device or VA-ECMO, and then decide whether the circulation to the end organs can be restored well enough to make the patient a suitable recipient within weeks or months.

Dr. Purkayastha's personal experience is that four to five weeks on a ventricular assist device restores the end-organ circulation so well that, more often than not, the patient becomes a very good transplant recipient. Kidney function returns to near normal, liver enzymes normalise, and chronic ischaemia resolves; patients with diabetes and small-vessel disease benefit particularly. The one drawback he notes is sensitisation: the device exposes the immune system to foreign material and multiple antigens, which can make matching a donor heart harder.

Destination therapy

Destination therapy is a permanent LVAD for a patient who will not have a transplant. Dr. Purkayastha described the typical candidate as someone aged 50 or 55 and above, with a reasonable expectation of life, who either does not want a transplant or is not a fit candidate for one. Destination therapy has grown because the risk of pump thrombosis, clotting inside the device, is now very low.

Durability has transformed the option. Earlier devices lasted three to five years at most. Current destination therapy devices are lasting 10 to 12 years and some longer: it is not uncommon, in his experience, to see patients who had their devices implanted in 2012 or 2013 still alive and reasonably well.

LVAD generations: from HeartMate I to HeartMate 3

LVADs are commonly grouped by generation:

• First generation: pulsatile pumps, such as the HeartMate I, that mimicked the heartbeat and were large and prone to wear.
• Second generation: continuous-flow axial pumps, such as the HeartMate II, smaller and more durable.
• Third generation: centrifugal pumps whose rotor is suspended magnetically or hydrodynamically, with no contact bearings.
• Current devices: fully magnetically levitated small centrifugal pumps, of which the HeartMate 3 is the standard example, with a very low risk of thrombosis.

Dr. Purkayastha places current practice at what he calls a "three plus" generation: magnetically levitated pumps that are now extremely small. For adults, the answer today, in his view, is the HeartMate 3. For children and adolescents he points to a smaller Jarvik pump that suits a body surface area of about 1.5 m², typically a child or adolescent with a congenital or childhood heart condition that has caused intractable heart failure.

LVAD cost: HeartMate 3, Jarvik and an Indian device

The device itself is the largest single cost. Dr. Purkayastha put the HeartMate 3 at close to $100,000 for the device alone, and described the Jarvik as considerably more affordable. Imported devices carry the full cost of American manufacturing and import duty.

Two developments he described could change that. At the time of the session in October 2025, Jarvik was developing a magnetically levitated third-generation pump and had applied for FDA approval. Separately, his team has collaborated with an Australian firm and the Indian Institute of Technology, Kanpur, on an LVAD of its own, which was in human trials and had just completed its second phase. He expected that the device might be ready for CE approval, and later FDA approval, as early as late 2026, and that it would allow an implantable long-term LVAD to be offered for less than half of what is paid today.

LVAD candidacy criteria

The question referring doctors most need answered is which patients will qualify, so that patients who will not are not sent abroad. Dr. Purkayastha's answer centres on the right heart, because an LVAD supports only the left ventricle and depends on the right ventricle to deliver blood to it.

The one investigation to send

If there is one investigation he asks for in every potential LVAD patient, rather than a series of echocardiograms, it is a right heart catheterisation: a thin catheter passed through a vein into the right side of the heart and the pulmonary artery to measure pressures directly. The study should report:

• the pulmonary pressures;
• the transpulmonary gradient (the difference between mean pulmonary artery pressure and left atrial filling pressure);
• the pulmonary artery pulsatility index (PAPi), a measure of right ventricular performance;
• the pulmonary vascular resistance, which should be below 5 Wood units, or reactive to pulmonary vasodilators if higher;
• the oxygen step-up across the chambers; and
• pulmonary vascular reactivity to vasodilators.

With those numbers in hand, in his words, "we are in". The haemodynamics of the pulmonary circulation are covered in more depth in his pulmonary hypertension masterclass.

Who remains a candidate

A patient whose failure is confined to the left heart, including failure with ischaemia-related complications, remains a candidate for LVAD therapy provided he or she does not have:

• intractable arrhythmias; or
• more than moderate tricuspid regurgitation with congestive symptoms, such as congestive hepatopathy (liver congestion from back-pressure) and other signs of right heart failure.

The one-week LVAD workup

The LVAD workup takes about a week. The results are run through a transplant or LVAD meeting or the heart failure clinic, after which the team can tell the patient whether he or she is a good candidate. Dr. Purkayastha is frank that a battery of basic blood tests and a very good echocardiogram will more or less show whether a patient is an LVAD candidate. To meet regulatory requirements, however, the workup must include a right heart catheterisation, a coronary angiogram and a CT scan of the chest, which measures the chest to size the device and plan the pocket in which it sits.

When to refer for an LVAD: at the beginning, not the end

Timing is where most foreign patients are lost. Of every 25 referrals Dr. Purkayastha receives, about two are properly worked up and at a stage where an LVAD or transplant can be discussed. Most arrive with an ejection fraction of 5 to 10%. Nobody, he notes, reaches an ejection fraction of 5% over a fortnight unless the cause is viral myocarditis.

The usual referral question, as he puts it, is not "what are the options for this heart failure patient?" but "he has been through everything, now what?" By then the options are very limited. If the ejection fraction is already 10% and the right heart has completely failed, a right heart catheterisation no longer makes much sense. Modern drugs can delay heart failure for a decade, but the long-term plan has to be discussed at the outset, not after years of outdated therapy have turned the heart into a dilated, failing chamber. He described a young man in his twenties whose left ventricle had dilated beyond 90 mm, for whom a transplant was the only remaining option.

His guidance to referring doctors is therefore simple: discuss the patient early in the heart failure journey, share the specific numbers and patient dimensions, and consider sending the patient early, even if only for a workup.

Related reading

For the drug therapy and surgical options that precede these decisions, see his separate masterclass on heart failure surgery, from valve repair to LVADs and transplant. The allocation rules, waiting times and costs that make an LVAD so important for a foreign patient are set out in donor heart allocation, waiting times and costs for foreign nationals. Questions doctors raised during the session, including on LVAD candidacy, are answered in the Live Discussion, and related procedures are collected under cardiac surgery.