LVADs and the Future of Heart Transplantation

For patients above 55, LVADs have to a reasonable extent already replaced transplantation as destination therapy — they can run fifteen years without complications on antiplatelet and anticoagulant therapy alone, with no immunosuppression needed. Three developments will transform deceased-donor transplant over the next decade: donation after circulatory death, which could roughly double the donor pool; ex vivo machine perfusion devices like the TransMedics Organ Care System, which keep a donor heart beating outside the body for twelve to twenty-four hours or more, making cross-continental transport feasible; and xenotransplantation, with genetically modified pig hearts already transplanted into two human recipients. It's unlikely any engineered device will fully replicate a natural heart, though — transplantation will stay relevant for at least the next fifteen to twenty-five years.

The first step is an urgent echocardiogram to establish ejection fraction precisely using Simpson's biplane method — the clinical picture at 35% and at 20% are entirely different territories. Below 20%, options are very limited; diuretics alone won't fully resolve the oedema. The Aquadex SmartFlow ultrafiltration system, with a 15ml prime volume removing 60 to 100ml of fluid per hour, is the logical next step when diuretics are failing. But with ejection fraction below 20% in the context of HIV and TB, and hypotension further constraining options, the situation is close to endgame — peritoneal dialysis is theoretically possible, but introducing a device into the body cavity of a patient with active communicable disease carries an infection risk that makes it unsafe in most circumstances.

The tricuspid valve is more often repaired than replaced. Even in a moderately aged patient in the 50 to 60 age group, if tricuspid valve replacement is necessary, a bioprosthetic valve is preferable to a mechanical valve — the right side is a low-pressure circuit, so a mechanical valve there carries a very high thrombosis risk that can embolise to the lung and be fatal. The preferred approach overall is tricuspid repair, either a traditional DeVega repair or an annuloplasty ring. TEER (TriClip for the tricuspid, MitraClip for the mitral) warrants real caution — for the mitral valve it's the surgical community's last resort, used only when every other repair technique and replacement are precluded by financial or anatomical constraint. With today's preoperative 3D imaging of the mitral annulus, a surgeon can nearly always plan intervention in advance instead.

The evidence is unambiguous: any form of alcohol predisposes to cardiac dysfunction. Traditional drinks have been examined alongside commercially available alcohol in studies, and the myth that red wine protects the heart has been comprehensively debunked. Chronic alcohol consumption damages the heart, full stop. Whether someone chooses to drink socially is a personal decision, but scientifically there is no basis for recommending any alcohol for cardiac health.

You do not manage it — you accept it, because that is your best option to open the coronary artery blockage. The bleeding risk is only a problem in a living patient. If the patient dies from a myocardial infarction for lack of intervention, there is no bleeding to manage.

Patients above 55, for whom LVADs now serve as destination therapy capable of running fifteen years without complications on antiplatelet and anticoagulant therapy alone, with no immunosuppression required.

A patient who received an LVAD in 2016 as a teenager has now, eleven years on at age 31, registered for a heart transplant as the device nears the end of its functional life, showing both how long an LVAD can last and that it is not permanent.

It extends organ donation beyond brain-death donors to include patients who experience cardiac arrest in hospital, a shift that could roughly double the donor pool.

Genetically modified pig hearts have been transplanted into two human recipients, one surviving ten months and the other just over a year.