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Review Article

Ventricular Assist Devices: Current State and Challenges OPEN ACCESS

[+] Author and Article Information
Siamak N. Doost

Biomechanical and Tissue Engineering Lab,
Faculty of Science, Engineering and Technology,
Swinburne University of Technology,
1 Alfred Street,
Hawthorn VIC 3122, Australia
e-mail: Sndoost@swin.edu.au

Liang Zhong

National Heart Research Institute of Singapore,
National Heart Centre,
5 Hospital Drive,
Singapore 169609, Singapore;
Duke-NUS Medical School,
8 College Road,
Singapore 169857, Singapore
e-mail: Zhong.liang@nhcs.com.sg

Yosry S. Morsi

Biomechanical and Tissue Engineering Lab,
Faculty of Science, Engineering and Technology,
Swinburne University of Technology,
1 Alfred Street,
Hawthorn VIC 3122, Australia
e-mail: ymorsi@swin.edu.au

1Corresponding authors.

Manuscript received December 12, 2016; final manuscript received May 27, 2017; published online August 8, 2017. Assoc. Editor: Michael Eggen.

J. Med. Devices 11(4), 040801 (Aug 08, 2017) (11 pages) Paper No: MED-16-1375; doi: 10.1115/1.4037258 History: Received December 12, 2016; Revised May 27, 2017

Cardiovascular disease (CVD), as the most prevalent human disease, incorporates a broad spectrum of cardiovascular system malfunctions/disorders. While cardiac transplantation is widely acknowledged as the optional treatment for patients suffering from end-stage heart failure (HF), due to its related drawbacks, such as the unavailability of heart donors, alternative treatments, i.e., implanting a ventricular assist device (VAD), it has been extensively utilized in recent years to recover heart function. However, this solution is thought problematic as it fails to satisfactorily provide lifelong support for patients at the end-stage of HF, nor does is solve the problem of their extensive postsurgery complications. In recent years, the huge technological advancements have enabled the manufacturing of a wide variety of reliable VAD devices, which provides a promising avenue for utilizing VAD implantation as the destination therapy (DT) in the future. Along with typical VAD systems, other innovative mechanical devices for cardiac support, as well as cell therapy and bioartificial cardiac tissue, have resulted in researchers proposing a new HF therapy. This paper aims to concisely review the current state of VAD technology, summarize recent advancements, discuss related complications, and argue for the development of the envisioned alternatives of HF therapy.

FIGURES IN THIS ARTICLE
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Cardiovascular disease (CVD) refers to a wide range of diseases relating to the cardiovascular system that, according to global reports [1], is the most prevalent disease with a high mortality rate in industrialized countries despite their advanced healthcare systems and high level of public awareness [2,3]. Heart failure (HF) or congestive HF, as a common type of CVD, refers to the inability of the heart to pump sufficient blood throughout the body. Cardiac transplantation and ventricular assist device (VAD) implantation are the two main treatment options widely prescribed by thoracic surgeons for patients suffering from end-stage HF. VADs are implementable electromechanical devices to improve patients' heart function, mainly proceeding with invasive open chest heart surgery [4]. VADs are not designed to replace the entire heart like a total artificial heart (TAH); rather, they fully/partially assist the heart in circulating blood throughout the body, which enables heart functionality restoration, coronary perfusion recovery, unloading excessive cardiac pressure and volume, and reducing myocardium tension, cardiomyocyte hypertrophy, and chronic ischemia [5]. While cardiac transplantation is considered to be the gold standard treatment for patients undergoing end-stage HF, in the last two decades, there has been a rising global demand for VAD implantation due to the aging population, the growing number of patients undergoing end-stage HF, the lack of heart donors, difficulties in finding a matching heart recipient, and the need for immediate action for candidates in a long “cardiac transplantation waiting list,” Therefore, due to the availability of the VAD system, the number of implantations of this mechanical device is rising annually, and it is now recognized as the best alternative treatment plan for end-stage heart failure [6].

Depending on the expected period of implantation, as well as the surgical purpose, a VAD operation can be divided into three main categories: (i) bridge-to-transplantation (BTT), which is short-term implantation for patients experiencing clinical deterioration until the availability of a heart donor, (ii) bridge-to-recovery (BTR), which is implantation after or during heart surgery to ensure the total recovery of the heart function or implantation after severe cardiogenic shock to stabilize cardiac circulation until a full evaluation of the patient can be undertaken and a final decision on the most suitable treatment is made by cardiologists, and (iii) destination therapy (DT), which is permanent implementation or a long-term treatment as a substitute for cardiac transplantation, particularly for those who are ineligible for transplantation due to a medical condition [7].

According to the literature, due to progress in the manufacturing of precise, accurate, smaller, and lighter VADs, this treatment has significantly improved survival rates and patients' lifestyles in recent years. Recent studies have revealed that VAD implantation results in reverse remodeling of the myocardial structure due to unloading the failing heart. The improvement of cardiac function can be achieved in various ways, including decreasing myocyte size, increasing myocyte contractility, improving mitochondrial function, decreasing myocyte apoptosis, and normalizing mitogen-activated protein kinase signaling [8]. Therefore, nowadays, this treatment is viewed as an alternative therapy for patients with end-stage HF [9]. However, despite promising improvements, VAD implantation still cannot be assumed as a lifetime support for patients.

As shown in Fig. 1, VADs fall under three main categories:

Left ventricular assist devices (LVAD): this is the most common VAD system and supports the failing left ventricle (LV) to pressurize and circulate oxygen-rich blood throughout the entire body of patients.

Right ventricular assist device (RVAD): this supports the failing right ventricle (RV) to push the blood through the pulmonary artery to the lungs for patients. RVADs are usually implanted for short-term treatment, particularly after heart surgery or LVAD implantation for the purpose of BTR.

Biventricular assist device (BiVAD): this supports both the LV and RV of patients suffering from total heart dysfunction at the same time. Implanting TAH is preferred to BiVAD as it is composed of a single part.

Depending on the type, model, and the manufacturer's preference, the mechanical details of intracorporeal (i.e., internal parts) and paracorporeal (i.e., external parts) components of VADs comprise the following three main parts:

  1. (1)Pump unit: circulates the blood. Typically, this unit is intracorporeal in implantable VADs, but paracorporeal in external VADs. The pump inflow and outflow cannulas should be grafted to the heart apex and artery (or vein), respectively, which can cause some postoperative complications.
  2. (2)Controller unit: monitors, synchronizes, and controls the pump unit. The controller, as the brain of the VADs, has various hazard and advisory alarms to notify of any possible failures, such as a declining power supply, pump, and driveline disconnections, or other possible mechanical failures of the internal parts, as well as some indicators of the patient's physiology.
  3. (3)Power unit: supplies the power to the driveline and controller. The power unit is usually paracorporeal with at least two separate battery packs to be used as a backup power source. In some VAD and TAH cases such as in AbioCor™ (ABIOMED Inc., Danvers, MA) and Arrow LionHeart (Arrow International, Reading, PA), a further internal backup battery with controller is located inside the body to supply power to the device for a short period of time when wires are accidentally torn or purposefully disconnected so the recipient can perform some personal life activity, such as taking a shower. In these models, transcutaneous energy transmission system or wireless charging technology has been utilized to charge the rechargeable internal battery for indefinite period.

All components of external VADs, i.e., transcutaneous VADs, are placed outside the body; the VAD should be therefore connected to the heart via conducting tubes through a small abdominal hole. The transcutaneous VADs are primarily suitable for short-term treatments, such as BTR, especially during/after heart surgery. On the other hand, most implantable (intracorporeal) VAD components are located within the body to be used as the BTT and DT therapy. In this type of VAD, only the power source and in some cases, the controller units of intracorporeal VADs are located outside the body to be replaced, repaired, or recharged quickly.

The pump configuration can be pulsatile or continuous. In the pulsatile configuration, known as first-generation VADs, the pump is made of a positive displacement pump with a pneumatic or electrical driveline to generate pulsatile flow, which is consistent with the heart's natural flow. In this type of pump, artificial heart valves with multiple moving parts are also attached to the pump unit in order to mimic the physiological blood circulation. The low durability of the device [10], excessive size, the need for further axillary equipment, extra moving parts, and the high rate of thrombosis are the major drawbacks of pulsatile VAD systems. On the whole, the excessive size of first-generation VADs necessitated the partial immobilization of the patient and the need to remain hospitalized until a cardiac transplantation had been undertaken. HeartMate I (previously Thermo Cardiosystems Inc., Waltham, MA, later owned by Thoratec Corporation, Pleasanton, CA, and now acquired by St. Jude Medical, Little Canada, MN), Novacor (World Heart Corp., Salt Lake City, UT, and now acquired by Heartware International Inc., Framingham, MA), LionHeart LVD2000 (Arrow International, Reading, PA) are examples of first-generation VAD systems with pulsatile volume-displacement pumps.

The configuration of second-generation VAD pumps is centrifugal, axial, or hybrid, which enables continuous, unidirectional blood flow with high durability. VADs with continuous blood flow are the most commonly used in clinical trials. As shown in Fig. 2, the direction of inflow and outflow is the main difference of continuous flow pumps. In centrifugal pumps, the blood enters the pump impeller along an axis of rotation and exits along the direction of the impeller plane, i.e., perpendicular to the axis of rotation. In axial pumps, blood enters and exits in the same direction of the impeller rotation axis. Axial pumps are small in size and weight in comparison to centrifugal pumps, but in contrast, they have a high rotational speed to meet a wide range of varying daily physiological requirements. The average rotational speed of the centrifugal and axial pump in VAD systems for full cardiac support is 2500 and 10,000 revolutions per minute (RPM), respectively.

In some modern VADs, a new configuration of the impeller, known as a hybrid pump or mixed-flow type, is used to optimize the pressure and cardiac output, such as in the CircuLite Synergy Micro-Pump (CircuLite, Inc., Germany, and now acquired by Heartware International Inc., Framingham, MA). In this configuration, blood enters through the rotating axis of the impeller and exits on an angle between 0 deg and 90 deg to this axis, which it is a combination of centrifugal and axial pump configurations. This type of pump is thought to be superior to earlier types as it delivers high range of blood (cardiac output) than the centrifugal type and has a higher output pressure than the axial pump. A simple schematic illustration of different impeller configurations is shown in Fig. 2. However, the implantation of a continuous flow pump is believed to improve cardiac hemodynamics, end-organ function, quality of life, and the functional capacity of patients compared to pulsatile pumps, due to their compact size [10].

Pulsatile pumps have been replaced by miniaturized, continuous flow pumps in second-generation VADs due to their compact configuration, reliable design, mechanical durability and also they only have one moving part. The implantation of a smaller continuous flow VAD, a replacement for the bulkier first-generation LVAD, substantially lowers the risk of postsurgery infection by 50%, which is the second underlying reason for mortality in LVAD recipients who have survived the initial 6 months after implantation [11]. Additionally, in comparison with pulsatile VADs, the rate of heart recovery can be increased by implanting a continuous flow VAD system [12]. Second-generation VAD systems are smaller and quieter as some of the components of pulsating VADs, such as the mechanical valve and reservoir chamber, have been eliminated [13]. Some studies on a group of patients after receiving a continuous-flow LVAD implantation indicate that the probability of survival free from stroke and device-related failure (in particular for patients received HeartMate II (Thoratec Corporation, Pleasanton, CA) in Refs. [10,14], and [15] studies) have been improved at first 2 years of implantation compared with pulsatile LVADs. In addition, the small size of the pump unit and driveline of new generation VADs enhances the possibility of VAD implantation in children or patients with small bodies with minimally invasive surgery [16] and also results in fast hospital discharge and improved patient mobilization and rehabilitation.

One of the main concerns of continuous flow VADs is hemolysis (red blood cell damage) due to the impeller rotations and contact bearings. To address this problem, third-generation VADs have been constructed with a similar pump configuration but a different bearing system. The current third-generation VAD systems are utilized with different and more sophisticated driveline and levitation configurations to suspend the impeller: (i) an external motor with a separate mechanical levitation system, (ii) direct drive systems with a separate magnetic levitation system, and (iii) a self-bearing or bearing-less system with a shared driveline and levitation magnetic stator [17]. The maglev (or magnet levitation) system in third-generation VADs eliminates the direct mechanical contact of the rotating parts by suspending the impeller without using a mechanical contact bearing, enhances mechanical durability, and significantly lowers the rate of hemolysis and thrombosis formation, and heat generation; consequently, the rate of VAD implantation as DT has increased in recent years [6,18].

The controller unit on continuous flow VADs, the most complex part of the VAD, monitors, synchronizes, and regulates the entire device, acting as the brain of the VAD. In continuous flow pumps, the cardiac output directly depends on the pump impeller rotational speed; therefore, the VAD must keep the cardiac output in the optimal range of operation by adjusting the outflow according to the daily physiological demand. If pump rotation decreases, the heart will not deliver enough blood to the body; subsequently, heart failure will progress as the cardiac output is less than the normal demand. Furthermore, if the flow is increased by the speed of the pump, the ventricle blood will be depleted instantly, which can lead to the occurrence of “suction event,” pulling the intraventricular septum toward the pump inflow cannula. Increasing the LV blood flow can also cause heart arrhythmia. As it is mentioned, the main function of the controller is to monitor and control the pump function such as flow and speed. The pump rotating speed in some VADs such as Jarvik 2000 (Jarvik Heart Inc., New York) or HeartMate II (Thoratec Corporation, Pleasanton, CA) can be manually adjusted by patient or physician according to daily activity level of the patient, but in some others such as InCor LVAD (Berlin Heart AG, Germany), they have been featured with smart controller to automatically regulate the impeller rotational speed to an optimal range. The aortic valve opening frequency can be used as an indicator to adjust the rotational speed of the impeller and avoid the suction event, but in practice, this timing varies during the day according to the patient's activity [19]. If the pump permanently has the same rotational speed during the day, the pump flow will not be sufficient when the patient's physical activity increases. To resolve this problem, some physiologically based control strategies have been proposed to regulate the impeller speed to meet the physiological demand for blood by automatically adjusting the pump rotation speed [20]. Furthermore, in some currently available VADs such as HeartMate III (Thoratec Corporation, Pleasanton, CA), the control unit has novel artificial pulse technology that enables pump washing to avoid the occurrence of the blood recirculation and stasis, which it is believed may reduce blood clotting and thrombus formation.

In addition, hazard and advisory alarms and sensors can be integrated into the controller unit or console to warn any possible failures, such as a decline in the power supply, disconnection of the pump and driveline, possible mechanical failure of the internal parts, as well as some indicators of the patient's physiology, such as the heartbeat, blood pressure, cardiac output, pump power consumption, impeller rotational speed, pulsatility index, and so forth. Such data are vital for VAD troubleshooting, for example, a sudden/gradual increase of power consumption or a change in the pulsatility index may relate to thrombus formation [21] or an incidence of the suction event. In some modern VADs, such as HeartAssist-5 (MicroMed Cardiovascular Inc., Houston, TX, and now acquired by ReliantHeart Inc., Houston, TX, and known as ReliantHeart Heart Assist-5), a remote control console has been used to regularly monitor device performance, regulate its function, and also notify the implanting center in case of emergency or device-related issues. Not only can this feature substantially cut the incidence of postsurgery hospitalization and associated cost, it can also increase the patient's confidence as they will know that the device's performance is being monitored by technicians to ensure it maintains its proper functioning and the implanting center will notify them quickly if device-related issues are detected.

Various commercial VADs, which are available on the market, are recommended by cardiac surgeons depending on the type and severity of the disease, the patient's medical condition, chest size, expected recovery time after extensive medical evaluation, and also financial considerations. The eligibility criteria of candidates should be assessed by undertaking extensive medical evaluations prior to consideration for implantation. This may include an echocardiogram, stress test, heart catheterization, and tests of other organ functionality, such as the kidney, lungs, and liver [22]. Some of the currently available VADs, which have been implanted successfully in recent years or are in the trial stage or are awaiting Food and Drug Administration (FDA) and Conformité Européenne (CE) mark approval [16,18,2331], are listed in Table 1. To date, HeartMate II (Thoratec Corporation, Pleasanton, CA) is the only available continuous flow VAD on the market to have received FDA approval to be implanted for both BTT and DT setting in 2008 and 2010, respectively [32]. In addition, the HeartWare Ventricular Assist System HVAD (HeartWare International Inc., Framingham, MA, and now acquired by Medtronic PLC, Ireland) is the second VAD model received FDA approval for only BTT purpose in 2012. Other devices have only received investigational device exemption (IDE) approval from FDA, which permits them to be manufactured for clinical investigational purposes in order to collect safety and effectiveness data to receive the final approval of FDA.

In addition to classic VADs, some state-of-the-art miniaturized VADs have also been designed, which eliminates the need for an invasive BTT operation (see Table 2). The percutaneous left ventricular assist device (pLVAD) is a type of miniaturized catheter-mounted VAD system, which can be implanted without invasive open chest surgery. These devices reduce cardiac workload and increase coronary and end-organ perfusion similar to BTT for a short period of time. They consist of a catheter with a micro-axial pump mounted at the tip of a catheter with intraventricular placement across the aortic valve [28]. Impella 2.5, CP, and 5.0/LD (Abiomed, Danvers, MA), and Thoratec Percutaneous Heart Pump (PHP) (Thoratec Corporation, Pleasanton, CA) are examples of catheter-mounted VADs. As shown in Fig. 3, in the catheter-mounted VAD, the pump and the blood outlet are placed in the ascending aorta in the distal tip of the cannula, whereas the blood inlet is located in the LV at the proximal end of the cannula. Impella devices have received FDA approval to be utilized as both partial and full LV support for a short period of time [33].

The insertion method of Impella 2.5, CP, and 5.0 and Thoratec PHP is a standard catheterization procedure through the femoral artery to place the pump into the ascending aorta and then the LV. But, Impella LD (Abiomed, Danvers, MA) requires a different procedure with minimally invasive open chest surgery to cut the ascending aorta and insert the device into the LV through the aortic valve. As shown in Fig. 3, the final placement of the pump in both procedures is similar. The function and correct placement of Impella VADs can be controlled during and after an operation by a console that monitors/analyzes the function and placement of the device [34].

TandemHeart™ (Cardiac Assist Technologies Inc., Pittsburgh, PA) is another type of pVAD with a different implanting configuration as BTT purpose up to 14 days until cardiac recovery or another treatment is used. In this type of VAD, as shown in Fig. 4, the pump is placed extracorporeally with percutaneous cannulas inserted through the femoral vein into the LA. The centrifugal pump withdraws blood from the LA, and then pumps it into one or both femoral arteries through arterial cannulas with a flow rate of 3.5–4.0 l/min and maximum rotational speed of 7500 rpm. The device has a console with auditory and visual alerts to monitor/notify performance and display several parameters, such as pump speed, power, as well as flow rate measured by an ultrasonic flow probe [36].

VAD implementation requires an extensive open heart surgical procedure to graft the device to the heart and aorta, as well as a cardiopulmonary bypass through the operation. In some cases, resurgery, device replacement, or even transplantation is required due to postsurgery complications or mechanical device failure; consequently, the postoperation recovery period is long and the associated risk of invasive operation is quite high [28]. Typically, LVADs discharge the blood from the apex of the LV by inserting an inflow conduit to deliver the pressurized blood into the ascending aorta by the end-to-side configuration pump outflow graft. The implanted parts are connected to the external parts via a percutaneous driveline through the abdominal cavity or postauricular connector. Some companies have designed miniaturized LVADs, which require a less invasive, less complicated surgical procedure, which mitigates the risk of surgery-related complications and reduces the recovery period and the complexity of the surgery. For instance, the CircuLite Synergy Micro-Pump, known as partial flow support VAD, requires a different surgical procedure as the device can be positioned in a small subcutaneous pocket in the upper chest under the clavicle, with minimally invasive surgery. It should be noted that this device is acquired by HeartWare International Inc, and now is a part of HeartWare Medtronic. The inflow and outflow cannula of the pump are simply connected to the left atrium and the subclavian artery, respectively. The internal parts are connected to the external parts via a percutaneous driveline [23]. Generally, patients need a regular intake of anticoagulation medicine to mitigate the risk of thrombosis after the VAD has been implanted, which also lowers the chance of serious consequences, such as stroke.

The majority of patients experience discomfort with the implant, particularly in the early weeks or months after the surgery, but the patient usually is able to return to normal daily life after 8–12 weeks. Moreover, VAD implementation has some unfavorable postoperative consequences, such as infection, HF, internal bleeding, blood clots, thrombosis, hemolysis, air embolism, stroke, and the mechanical failure of the VAD. According to the published reports, the major reasons for death after VAD implantation include RV failure, thromboembolism, infection, and neurological events [37,38].

The reliability and durability of the device, including the mechanical parts, sensors, and the controller, is another concern that relates to the specific features of the device and its manufacturer. The durability of first-generation VAD systems is only 1–3 years, while second-generation VADs can function for up to 5.5 years. This durability is substantially increased in third-generation VADs due to the improvement of the levitation system and eliminating any contacts with mechanical surfaces and thus heat generation and surface wear [39].

Some serious complications and limitations of current VADs are as follows:

  • (i)They can lead to infection, bleeding, blood clots, thrombosis, hemolysis, air embolism, and stroke mainly due to direct contact of the blood with the internally implanted parts of the device;
  • (ii)They can lead to infection due to percutaneous driveline and connectors, as well as the high risk of driveline breakage;
  • (iii)Invasive inflow/outflow conduits are grafted to the heart apex and aorta;
  • (iv)They can cause cerebral and peripheral thromboembolism;
  • (v)They can lead to RV failure, arrhythmias, and alter RV geometry and septal position;
  • (vi)The continuous pumping of blood is unlike natural pulsatile blood circulation;
  • (vii)The inability to automatically synchronize or coordinate the device to meet the varying physiological demand for blood when the patient is engaging in different daily activities;
  • (viii)They reduce the patients' quality of life;
  • (ix)The high cost of surgery, hospitalization, and postsurgery follow-up.

However, despite the huge advancements in VAD system manufacturing, aforementioned drawbacks have not been completely addressed yet. The majority of these concerns still remain, due to directly connecting to the physical configuration of the available VADs; therefore, by taking into consideration all of these limitations, a novel VAD system is required to effectively address all or some of these serious concerns. Thus, implanting a non-blood-contacting device could significantly resolve common postsurgery complications caused by the VAD.

Recently, to address either all or some of the aforementioned VAD device-related complications, some attempts have been undertaken to introduce a novel non-blood-contacting device, which often is called the cardiac support system (CSS). The aim of CSS is to implant a device outside of the heart without having direct contact with the circulating blood. These devices could improve cardiac output without using a pump to pressurize the circulating blood. The main advantages of the non-blood-contacting VAD are as follows: it reduces the risk of blood contamination, infection, internal bleeding, blood clotting, hemolysis, stroke and decreases surgical costs as implantation and removal does not require a lengthy process.

Some devices, such as direct mechanical ventricular actuation (DMVA) [40], HeartPatch direct cardiac compression (HeartPatch-DCC device; Heart Assist Technologies, Australia) [41], MYO-VAD™ (Biophan Technologies Inc., New York) [42], electromechanical ventricular assist device [43], CorCap CSD (Acorn Cardiovascular Inc., Saint Paul, MN) [44], apical torsion cardiac assist device (tVAD) [45], and C-Pulse® (Sunshine Heart Inc., CA) [46] have been proposed over the last two decades to partially address the drawbacks of typical VAD systems.

DMVA has been designed with a unique heart surrounding configuration to massage both ventricles simultaneously via pneumatic force to mimic myocardial motion during both systolic and diastolic phases. The surrounding sac has been made of two polymer layers, a flexible inner layer as an actuating diaphragm and a flexible or rigid outer layer as the device housing. By acting as a positive pneumatic force on the flexible diaphragm, it compresses both ventricles to take the systolic configuration, while the negative force reshapes it into the initial configuration of the diastolic phase. The human feasibility study of DMVA revealed high hemodynamic stabilization and cardiac improvement immediately after implantation [40,47,48]. HeartPatch-DCC acts similarly to DMVA, but with a nonsurrounding configuration made of two isolated, inflatable patches to compress both ventricles together with separate pneumatic forces [41]. MYO-VAD™ is similar to DMVA, being made of a polymeric cup, which covers the entire heart enclosure to improve heart functionality by compressing and expanding both ventricles simultaneously. The animal study using the MYO-VAD prototype illustrated an improvement of heart functionality after implantation [43,49].

Another device also proposed by the Boccaccio research group [43] consists of three rings of wires and springs with a stepper motor. The step motor twists the springs to reduce the rings' diameter to generate sufficient load to compress the myocardial surface during systole and release the spring load by returning to the initial position at diastole [43]. CorCap CSD is a mesh-like biocompatible sac wrapped around the heart surface similar to myocardial enforcement to prevent further enlargement of the failing heart and to reload the myocardial wall stress during systole, which is similar to cardiomyoplasty surgery [44,50,51]. tVAD is a torsional device attached to the heart apex to contract both ventricles by twisting the heart with a rotary servomotor [45] Finally, C-Pulse® is another innovative implantable device introduced for the treatment of heart failure with an extra-aortic balloon attached to the ascending aorta to push further blood to the aorta and coronary artery after each heartbeat by pressuring/inflating the balloon with air after each heartbeat. This action can improve heart function, enhance cardiac output, and decrease heart load since further oxygen-rich blood is pushed to the coronary arteries and arterial network. In this device, a heart rate detector sensor is attached to customize the synchronization of balloon inflation according to the patient's heartbeat [46]. In addition to these devices, in our research group at the Swinburne University of Technology, a novel wireless VAD system with non-blood-contact surfaces is under investigation to synchronize and coordinate the LV and RV, simultaneously.

Finally, other envisioned therapies, such as using a tissue engineering idea and cell therapies, have attracted the attention of researchers to recover damaged heart myocardium and avoid further progression of myocardial dilation after myocardial infarction. The idea behind tissue engineering is to develop an artificially created cellular environment, which is suitable for the integration, vascularization, and connection of natural tissue and a bioengineered scaffold [52]. Myocardial tissue engineering refers to a concept to recover heart function by exchanging the noncontractile scar tissue remaining after heart failure with a bioartificial cardiac tissue patch [53] by utilizing a porous scaffold made of either natural or biosynthetic materials, to guide the differentiation of cells and generation of tissue. Recently, researchers [54] developed an in vivo punch-like myocardial heart tissue, named the biological ventricular assist device (BioVAD), with in vivo results of 2 weeks survival in a rat. The complexity of generating the cellular composition of the myocardium can be primarily attributed to the fact that the myocardial muscle has a very dense composition with overlapping arrays of muscle cells organized in different circumferential alignments; thus, some challenging criterion such as biocompatibility, biodegradability, mechanical functionality, injectability, and envisioned application time should be considered when generating the myocardial tissue [55]. Cell therapy is another envisioned treatment option to restore the functionality of a failing heart by replacing the dead cardiac cells immediately after myocardial infarction with stem cells. The currently available treatments prevent further damage of the cells to reduce further heart attack, but cell therapy, as a regenerative therapy, not only potentially prevents the risk of additional damage, it can also repair damaged cardiomyocytes [56]. Substantial progress has been made in tissue engineering and cell therapy over the last decade, and these envisioned treatments are now progressing at a rapid pace but still are in the early stages of progress and need huge improvement in order to be suitable for clinical application.

VADs are implantable electromechanical devices to assist patients experiencing end-stage HF. Demand for VAD implantation is globally increasing due to the lack of heart donors compared to the huge number of patients who are hospitalized annually, suffering from end-stage HF; therefore, implanting a VAD is becoming more frequent in HF therapy. In this review paper, it was revealed that despite the huge advancements in recent years in manufacturing reliable VADs requiring minimally invasive procedures, they are not fully suitable for the lifetime support of patients due to unresolved device-related complications. Thus, the need for manufacturing a novel VAD with less device-related complications with the ability to mimic natural heart physiology is an urgent requirement that can be achieved by huge multidisciplinary collaboration of researchers. Even though some attempts have been undertaken to address this issue either completely or partially, such as BiVAD, the outcome is still unsatisfactory as it has not been placed in the clinical trial stage yet.

The authors would like to acknowledge the financial support received from the Swinburne University of Technology and National Heart Research Institute of Singapore to carry out this research.

  • BioVAD =

    biological ventricular assist device

  • BiVAD =

    biventricular assist device

  • BTR =

    bridge-to-recovery

  • BTT =

    bridge-to-transplantation

  • CE =

    Conformité Européenne

  • CSS =

    cardiac support system

  • CVD =

    cardiovascular disease

  • DCC =

    direct cardiac compression

  • DMVA =

    direct mechanical ventricular actuation

  • DT =

    destination therapy

  • FDA =

    food and drug administration

  • HF =

    heart failure

  • IDE =

    investigational device exemption

  • LV =

    left ventricular

  • LVAD =

    left ventricular assist devices

  • pLVAD =

    percutaneous left ventricular assist device

  • RV =

    right ventricular

  • RVAD =

    right ventricular assist device

  • TAH =

    total artificial heart

  • tVAD =

    torsion cardiac assist device

  • VAD =

    ventricular assist device

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Blaxall, B. C. , Tschannen-Moran, B. M. , Milano, C. A. , and Koch, W. J. , 2003, “ Differential Gene Expression and Genomic Patient Stratification Following Left Ventricular Assist Device Support,” J. Am. Coll. Cardiol., 41(7), pp. 1096–1106. [CrossRef] [PubMed]
Trochu, J.-N. , Leprince, P. , Bielefeld-Gomez, M. , Bastien, O. , Beauvais, F. , Gueffet, J.-P. , Logeart, D. , Isnard, R. , Iliou, M.-C. , Leclercq, C. , and Girard, C. , 2012, “ Left Ventricle Assist Device: When and Which Patients Should We Refer?,” Arch. Cardiovasc. Dis., 105(2), pp. 114–121. [CrossRef] [PubMed]
Slaughter, M. S. , Rogers, J. G. , Milano, C. A. , Russell, S. D. , Conte, J. V. , Feldman, D. , Sun, B. , Tatooles, A. J. , Delgado, R. M. I. , Long, J. W. , Wozniak, T. C. , Ghumman, W. , Farrar, D. J. , and Frazier, O. H. , 2009, “ Advanced Heart Failure Treated With Continuous-Flow Left Ventricular Assist Device,” N. Engl. J. Med., 361(23), pp. 2241–2251. [CrossRef] [PubMed]
Trachtenberg, B. H. , Cordero-Reyes, A. , Elias, B. , and Loebe, M. , 2015, “ A Review of Infections in Patients With Left Ventricular Assist Devices: Prevention, Diagnosis and Management,” Methodist DeBakey Cardiovasc. J., 11(1), pp. 28–32. [CrossRef] [PubMed]
Cheng, A. , Williamitis, C. A. , and Slaughter, M. S. , 2014, “ Comparison of Continuous-Flow and Pulsatile-Flow Left Ventricular Assist Devices: Is There an Advantage to Pulsatility?,” Ann. Cardiothorac. Surg., 3(6), pp. 573–581. [PubMed]
Vlodaver, Z. , Wilson, R. F. , and Garry, D. J. , 2012, Coronary Heart Disease: Clinical, Pathological, Imaging, and Molecular Profiles, Springer, New York.
Park, S. J. , Milano, C. A. , Tatooles, A. J. , Rogers, J. G. , Adamson, R. M. , Steidley, D. E. , Ewald, G. A. , Sundareswaran, K. S. , Farrar, D. J. , and Slaughter, M. S. , 2012, “ Outcomes in Advanced Heart Failure Patients With Left Ventricular Assist Devices for Destination Therapy,” Circ.: Heart Failure, 5(2), pp. 241–248. [CrossRef]
Jorde, U. P. , Khushwaha, S. S. , Tatooles, A. J. , Naka, Y. , Bhat, G. , Long, J. W. , Horstmanshof, D. , Kormos, R. L. , Teuteberg, J. J. , Slaughter, M. S. , Birks, E. J. , Farrar, D. J. , and Park, S. J. , 2013, “ Two-Year Outcomes in the Destination Therapy Post-FDA-Approval Study With a Continuous Flow Left Ventricular Assist Device: A Prospective Study Using the INTERMACS Registry,” J. Heart Lung Transplant., 32(Suppl. 4), p. S10. [CrossRef]
Frazier, O. H. , and Parnis, S. M. , 2014, “ Ventricular Assist Devices,” Textbook of Organ Transplantation, A. D. Kirk, S. J. Knechtle, C. P. Larsen, J. C. Madsen, T. C. Pearson, and S. A. Webber , eds., Wiley, Hoboken, NJ, pp. 554–562. [CrossRef]
Pagani, F. D. , 2008, “ Continuous-Flow Rotary Left Ventricular Assist Devices With ‘3rd Generation’ Design,” Semin. Thoracic Cardiovasc. Surg., 20(3), pp. 255–263. [CrossRef]
Morshuis, M. , El-Banayosy, A. , Arusoglu, L. , Koerfer, R. , Hetzer, R. , Wieselthaler, G. , Pavie, A. , and Nojiri, C. , 2009, “ European Experience of Duraheart™ Magnetically Levitated Centrifugal Left Ventricular Assist System,” Eur. J. Cardio-Thoracic Surg., 35(6), pp. 1020–1028. [CrossRef]
Zhou, M.-D. , Yang, C. , Liu, Z. , Cysyk, J. , and Zheng, S.-Y. , 2012, “ An Implantable Fabry-Pérot Pressure Sensor Fabricated on Left Ventricular Assist Device for Heart Failure,” Biomed. Microdevices, 14(1), pp. 235–245. [CrossRef] [PubMed]
Moscato, F. , Arabia, M. , Colacino, F. M. , Naiyanetr, P. , Danieli, G. A. , and Schima, H. , 2010, “ Left Ventricle Afterload Impedance Control by an Axial Flow Ventricular Assist Device: A Potential Tool for Ventricular Recovery,” Artif. Organs, 34(9), pp. 736–744. [CrossRef] [PubMed]
Tchantchaleishvili, V. , Sagebin, F. , Ross, R. E. , Hallinan, W. , Schwarz, K. Q. , and Massey, H. T. , 2014, “ Evaluation and Treatment of Pump Thrombosis and Hemolysis,” Ann. Cardiothorac. Surg., 3(5), pp. 490–495. [PubMed]
Givertz, M. M. , 2011, “ Ventricular Assist Devices: Important Information for Patients and Families,” Circulation, 124(12), pp. e305–e311. [CrossRef] [PubMed]
Molina, E. J. , and Boyce, S. W. , 2013, “ Current Status of Left Ventricular Assist Device Technology,” Semin. Thoracic Cardiovasc. Surg., 25(1), pp. 56–63. [CrossRef]
Wieselthaler, G. M. , Schima, H. , Hiesmayr, M. , Pacher, R. , Laufer, G. , Noon, G. P. , DeBakey, M. , and Wolner, E. , 2000, “ First Clinical Experience With the Debakey VAD Continuous-Axial-Flow Pump for Bridge to Transplantation,” Circulation, 101(4), pp. 356–359. [CrossRef] [PubMed]
Hoshi, H. , Shinshi, T. , and Takatani, S. , 2006, “ Third-Generation Blood Pumps With Mechanical Noncontact Magnetic Bearings,” Artif. Organs, 30(5), pp. 324–338. [CrossRef] [PubMed]
Chusri, Y. , Diloksumpan, P. , and Naiyanetr, P. , 2013, “ Current Left Ventricular Assist Device,” Sixth Biomedical Engineering International Conference (BMEiCON), Krabi, Thailand, Oct. 23–25, pp. 1–4.
Loforte, A. , Montalto, A. , Ranocchi, F. , Casali, G. , Luzi, G. , Monica, P. L. D. , Sbaraglia, F. , Polizzi, V. , Distefano, G. , and Musumeci, F. , 2009, “ Heartmate II Axial-Flow Left Ventricular Assist System: Management, Clinical Review and Personal Experience,” J. Cardiovasc. Med., 10(10), pp. 765–771. [CrossRef]
Giridharan, G. A. , Lee, T. J. , Ising, M. , Sobieski, M. A. , Koenig, S. C. , Gray, L. A. , and Slaughter, M. S. , 2012, “ Miniaturization of Mechanical Circulatory Support Systems,” Artif. Organs, 36(8), pp. 731–739. [CrossRef] [PubMed]
Timms, D. , 2011, “ A Review of Clinical Ventricular Assist Devices,” Med. Eng. Phys., 33(9), pp. 1041–1047. [CrossRef] [PubMed]
Farrar, D. , Bourque, K. , Reichenbach, S. , Muller, P. , and Peri, L. , 2014, “ Innovation Update,” Ventricular Assist Devices in Advanced-Stage Heart Failure, S. Kyo , ed., Springer, Tokyo, Japan, pp. 131–142. [CrossRef]
Estep, J. D. , Chang, S. M. , Bhimaraj, A. , Torre-Amione, G. , Zoghbi, W. A. , and Nagueh, S. F. , 2012, “ Imaging for Ventricular Function and Myocardial Recovery on Nonpulsatile Ventricular Assist Devices,” Circulation, 125(18), pp. 2265–2277. [CrossRef] [PubMed]
John, R. , Naka, Y. , Smedira, N. G. , Starling, R. , Jorde, U. , Eckman, P. , Farrar, D. J. , and Pagani, F. D. , 2011, “ Continuous Flow Left Ventricular Assist Device Outcomes in Commercial Use Compared With the Prior Clinical Trial,” Ann. Thoracic Surg., 92(4), pp. 1406–1413. [CrossRef]
Bogaev, R. , Delgado, R. , Taegtmeyer, H. , and Frazier, O. H. , 2011, “ Circulatory Assist Device in Heart Failure,” Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, B. Robert, M. Douglas, Z. Douglas, and L. Peter , eds., Elsevier—Health Sciences Division, Philadelphia, PA, pp. 818–833. [CrossRef]
Abiomed, 2010, “ Impella® LD With the Impella® Console Instructions for Use & Clinical Reference Manual,” Abiomed, Inc., Danvers, MA.
THI, 2016, “ Tandemheart pVAD,” Texas Heart Institute, Houston, TX, accessed Nov. 29, 2016, http://www.texasheart.org/Research/Devices/tandemheart.cfm
Kar, B. , Adkins, L. E. , Civitello, A. B. , Loyalka, P. , Palanichamy, N. , Gemmato, C. J. , Myers, T. J. , Gregoric, I. D. , and Delgado, R. M. , 2006, “ Clinical Experience With the Tandemheart® Percutaneous Ventricular Assist Device,” Tex. Heart Inst. J., 33(2), pp. 111–115. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1524679/ [PubMed]
Klein, A. A. , Lewis, C. J. , and Madsen, J. C. , 2011, Organ Transplantation: A Clinical Guide, Cambridge University Press, New York. [CrossRef]
Gross, D. R. , 1999, “ Concerning Thromboembolism Associated With Left Ventricular Assist Devices,” Cardiovasc. Res., 42(1), pp. 45–47. [CrossRef] [PubMed]
Rigatelli, G. , Santini, F. , and Faggian, G. , 2012, “ Past and Present of Cardiocirculatory Assist Devices: A Comprehensive Critical Review,” J. Geriatr. Cardiol., 9(4), pp. 389–400. [PubMed]
Anstadt, M. P. , Bartlett, R. L. , Malone, J. P. , Brown, G. R. , Martin, S. , Nolan, D. J. , Oberheu, K. H. , and Anstadt, G. L. , 1991, “ Direct Mechanical Ventricular Actuation for Cardiac Arrest in Humans: A Clinical Feasibility Trial,” Chest, 100(1), pp. 86–92. [CrossRef] [PubMed]
Mau, J. , Menzie, S. , Huang, Y. , Ward, M. , and Hunyor, S. , 2011, “ Nonsurround, Nonuniform, Biventricular-Capable Direct Cardiac Compression Provides Frank-Starling Recruitment Independent of Left Ventricular Septal Damage,” J. Thoracic Cardiovasc. Surg., 142(1), pp. 209–215. [CrossRef]
Abiomed, 2014, “ Abiocor® Implantable Replacement Heart Instructions for Use,” Abiomed, Inc., Danvers, MA, accessed Dec. 19, 2014, https://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4149b2_01_ABIOMED%20INSTRUCTIONS%20FOR%20USE.pdf
Boccaccio, A. , Carbone, C. , Galietti, U. , Mastropasqua, F. , and Pappalettere, C. , 2011, “ A Novel Electro-Mechanical Ventricular Assist Device for Refractory Cardiac Insufficiency,” IEEE International Workshop on Medical Measurements and Applications (MeMeA), Bari, Italy, May 30–31, pp. 221–224.
Starling, R. C. , and Jessup, M. , 2004, “ Worldwide Clinical Experience With the Corcap™ Cardiac Support Device,” J. Card. Failure, 10(Suppl. 6), pp. S225–S233. [CrossRef]
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Anstadt, M. P. , Anstadt, G. L. , and Lowe, J. E. , 1991, “ Direct Mechanical Ventricular Actuation: A Review,” Resuscitation, 21(1), pp. 7–23. [CrossRef] [PubMed]
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Garbade, J. , Bittner, H. B. , Barten, M. J. , and Mohr, F.-W. , 2011, “ Current Trends in Implantable Left Ventricular Assist Devices,” Cardiol. Res. Pract., 2011, pp. 1–9. [CrossRef]
Wilson, S. R. , Givertz, M. M. , Stewart, G. C. , and Mudge, J. G. H. , 2009, “ Ventricular Assist Devices: The Challenges of Outpatient Management,” J. Am. Coll. Cardiol., 54(18), pp. 1647–1659. [CrossRef] [PubMed]
Blaxall, B. C. , Tschannen-Moran, B. M. , Milano, C. A. , and Koch, W. J. , 2003, “ Differential Gene Expression and Genomic Patient Stratification Following Left Ventricular Assist Device Support,” J. Am. Coll. Cardiol., 41(7), pp. 1096–1106. [CrossRef] [PubMed]
Trochu, J.-N. , Leprince, P. , Bielefeld-Gomez, M. , Bastien, O. , Beauvais, F. , Gueffet, J.-P. , Logeart, D. , Isnard, R. , Iliou, M.-C. , Leclercq, C. , and Girard, C. , 2012, “ Left Ventricle Assist Device: When and Which Patients Should We Refer?,” Arch. Cardiovasc. Dis., 105(2), pp. 114–121. [CrossRef] [PubMed]
Slaughter, M. S. , Rogers, J. G. , Milano, C. A. , Russell, S. D. , Conte, J. V. , Feldman, D. , Sun, B. , Tatooles, A. J. , Delgado, R. M. I. , Long, J. W. , Wozniak, T. C. , Ghumman, W. , Farrar, D. J. , and Frazier, O. H. , 2009, “ Advanced Heart Failure Treated With Continuous-Flow Left Ventricular Assist Device,” N. Engl. J. Med., 361(23), pp. 2241–2251. [CrossRef] [PubMed]
Trachtenberg, B. H. , Cordero-Reyes, A. , Elias, B. , and Loebe, M. , 2015, “ A Review of Infections in Patients With Left Ventricular Assist Devices: Prevention, Diagnosis and Management,” Methodist DeBakey Cardiovasc. J., 11(1), pp. 28–32. [CrossRef] [PubMed]
Cheng, A. , Williamitis, C. A. , and Slaughter, M. S. , 2014, “ Comparison of Continuous-Flow and Pulsatile-Flow Left Ventricular Assist Devices: Is There an Advantage to Pulsatility?,” Ann. Cardiothorac. Surg., 3(6), pp. 573–581. [PubMed]
Vlodaver, Z. , Wilson, R. F. , and Garry, D. J. , 2012, Coronary Heart Disease: Clinical, Pathological, Imaging, and Molecular Profiles, Springer, New York.
Park, S. J. , Milano, C. A. , Tatooles, A. J. , Rogers, J. G. , Adamson, R. M. , Steidley, D. E. , Ewald, G. A. , Sundareswaran, K. S. , Farrar, D. J. , and Slaughter, M. S. , 2012, “ Outcomes in Advanced Heart Failure Patients With Left Ventricular Assist Devices for Destination Therapy,” Circ.: Heart Failure, 5(2), pp. 241–248. [CrossRef]
Jorde, U. P. , Khushwaha, S. S. , Tatooles, A. J. , Naka, Y. , Bhat, G. , Long, J. W. , Horstmanshof, D. , Kormos, R. L. , Teuteberg, J. J. , Slaughter, M. S. , Birks, E. J. , Farrar, D. J. , and Park, S. J. , 2013, “ Two-Year Outcomes in the Destination Therapy Post-FDA-Approval Study With a Continuous Flow Left Ventricular Assist Device: A Prospective Study Using the INTERMACS Registry,” J. Heart Lung Transplant., 32(Suppl. 4), p. S10. [CrossRef]
Frazier, O. H. , and Parnis, S. M. , 2014, “ Ventricular Assist Devices,” Textbook of Organ Transplantation, A. D. Kirk, S. J. Knechtle, C. P. Larsen, J. C. Madsen, T. C. Pearson, and S. A. Webber , eds., Wiley, Hoboken, NJ, pp. 554–562. [CrossRef]
Pagani, F. D. , 2008, “ Continuous-Flow Rotary Left Ventricular Assist Devices With ‘3rd Generation’ Design,” Semin. Thoracic Cardiovasc. Surg., 20(3), pp. 255–263. [CrossRef]
Morshuis, M. , El-Banayosy, A. , Arusoglu, L. , Koerfer, R. , Hetzer, R. , Wieselthaler, G. , Pavie, A. , and Nojiri, C. , 2009, “ European Experience of Duraheart™ Magnetically Levitated Centrifugal Left Ventricular Assist System,” Eur. J. Cardio-Thoracic Surg., 35(6), pp. 1020–1028. [CrossRef]
Zhou, M.-D. , Yang, C. , Liu, Z. , Cysyk, J. , and Zheng, S.-Y. , 2012, “ An Implantable Fabry-Pérot Pressure Sensor Fabricated on Left Ventricular Assist Device for Heart Failure,” Biomed. Microdevices, 14(1), pp. 235–245. [CrossRef] [PubMed]
Moscato, F. , Arabia, M. , Colacino, F. M. , Naiyanetr, P. , Danieli, G. A. , and Schima, H. , 2010, “ Left Ventricle Afterload Impedance Control by an Axial Flow Ventricular Assist Device: A Potential Tool for Ventricular Recovery,” Artif. Organs, 34(9), pp. 736–744. [CrossRef] [PubMed]
Tchantchaleishvili, V. , Sagebin, F. , Ross, R. E. , Hallinan, W. , Schwarz, K. Q. , and Massey, H. T. , 2014, “ Evaluation and Treatment of Pump Thrombosis and Hemolysis,” Ann. Cardiothorac. Surg., 3(5), pp. 490–495. [PubMed]
Givertz, M. M. , 2011, “ Ventricular Assist Devices: Important Information for Patients and Families,” Circulation, 124(12), pp. e305–e311. [CrossRef] [PubMed]
Molina, E. J. , and Boyce, S. W. , 2013, “ Current Status of Left Ventricular Assist Device Technology,” Semin. Thoracic Cardiovasc. Surg., 25(1), pp. 56–63. [CrossRef]
Wieselthaler, G. M. , Schima, H. , Hiesmayr, M. , Pacher, R. , Laufer, G. , Noon, G. P. , DeBakey, M. , and Wolner, E. , 2000, “ First Clinical Experience With the Debakey VAD Continuous-Axial-Flow Pump for Bridge to Transplantation,” Circulation, 101(4), pp. 356–359. [CrossRef] [PubMed]
Hoshi, H. , Shinshi, T. , and Takatani, S. , 2006, “ Third-Generation Blood Pumps With Mechanical Noncontact Magnetic Bearings,” Artif. Organs, 30(5), pp. 324–338. [CrossRef] [PubMed]
Chusri, Y. , Diloksumpan, P. , and Naiyanetr, P. , 2013, “ Current Left Ventricular Assist Device,” Sixth Biomedical Engineering International Conference (BMEiCON), Krabi, Thailand, Oct. 23–25, pp. 1–4.
Loforte, A. , Montalto, A. , Ranocchi, F. , Casali, G. , Luzi, G. , Monica, P. L. D. , Sbaraglia, F. , Polizzi, V. , Distefano, G. , and Musumeci, F. , 2009, “ Heartmate II Axial-Flow Left Ventricular Assist System: Management, Clinical Review and Personal Experience,” J. Cardiovasc. Med., 10(10), pp. 765–771. [CrossRef]
Giridharan, G. A. , Lee, T. J. , Ising, M. , Sobieski, M. A. , Koenig, S. C. , Gray, L. A. , and Slaughter, M. S. , 2012, “ Miniaturization of Mechanical Circulatory Support Systems,” Artif. Organs, 36(8), pp. 731–739. [CrossRef] [PubMed]
Timms, D. , 2011, “ A Review of Clinical Ventricular Assist Devices,” Med. Eng. Phys., 33(9), pp. 1041–1047. [CrossRef] [PubMed]
Farrar, D. , Bourque, K. , Reichenbach, S. , Muller, P. , and Peri, L. , 2014, “ Innovation Update,” Ventricular Assist Devices in Advanced-Stage Heart Failure, S. Kyo , ed., Springer, Tokyo, Japan, pp. 131–142. [CrossRef]
Estep, J. D. , Chang, S. M. , Bhimaraj, A. , Torre-Amione, G. , Zoghbi, W. A. , and Nagueh, S. F. , 2012, “ Imaging for Ventricular Function and Myocardial Recovery on Nonpulsatile Ventricular Assist Devices,” Circulation, 125(18), pp. 2265–2277. [CrossRef] [PubMed]
John, R. , Naka, Y. , Smedira, N. G. , Starling, R. , Jorde, U. , Eckman, P. , Farrar, D. J. , and Pagani, F. D. , 2011, “ Continuous Flow Left Ventricular Assist Device Outcomes in Commercial Use Compared With the Prior Clinical Trial,” Ann. Thoracic Surg., 92(4), pp. 1406–1413. [CrossRef]
Bogaev, R. , Delgado, R. , Taegtmeyer, H. , and Frazier, O. H. , 2011, “ Circulatory Assist Device in Heart Failure,” Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, B. Robert, M. Douglas, Z. Douglas, and L. Peter , eds., Elsevier—Health Sciences Division, Philadelphia, PA, pp. 818–833. [CrossRef]
Abiomed, 2010, “ Impella® LD With the Impella® Console Instructions for Use & Clinical Reference Manual,” Abiomed, Inc., Danvers, MA.
THI, 2016, “ Tandemheart pVAD,” Texas Heart Institute, Houston, TX, accessed Nov. 29, 2016, http://www.texasheart.org/Research/Devices/tandemheart.cfm
Kar, B. , Adkins, L. E. , Civitello, A. B. , Loyalka, P. , Palanichamy, N. , Gemmato, C. J. , Myers, T. J. , Gregoric, I. D. , and Delgado, R. M. , 2006, “ Clinical Experience With the Tandemheart® Percutaneous Ventricular Assist Device,” Tex. Heart Inst. J., 33(2), pp. 111–115. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1524679/ [PubMed]
Klein, A. A. , Lewis, C. J. , and Madsen, J. C. , 2011, Organ Transplantation: A Clinical Guide, Cambridge University Press, New York. [CrossRef]
Gross, D. R. , 1999, “ Concerning Thromboembolism Associated With Left Ventricular Assist Devices,” Cardiovasc. Res., 42(1), pp. 45–47. [CrossRef] [PubMed]
Rigatelli, G. , Santini, F. , and Faggian, G. , 2012, “ Past and Present of Cardiocirculatory Assist Devices: A Comprehensive Critical Review,” J. Geriatr. Cardiol., 9(4), pp. 389–400. [PubMed]
Anstadt, M. P. , Bartlett, R. L. , Malone, J. P. , Brown, G. R. , Martin, S. , Nolan, D. J. , Oberheu, K. H. , and Anstadt, G. L. , 1991, “ Direct Mechanical Ventricular Actuation for Cardiac Arrest in Humans: A Clinical Feasibility Trial,” Chest, 100(1), pp. 86–92. [CrossRef] [PubMed]
Mau, J. , Menzie, S. , Huang, Y. , Ward, M. , and Hunyor, S. , 2011, “ Nonsurround, Nonuniform, Biventricular-Capable Direct Cardiac Compression Provides Frank-Starling Recruitment Independent of Left Ventricular Septal Damage,” J. Thoracic Cardiovasc. Surg., 142(1), pp. 209–215. [CrossRef]
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Figures

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Fig. 1

A schematic illustration of the different categories of VADs

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Fig. 2

A schematic illustration of different types of pump impellers used in the construction of continuous flow pumps

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Fig. 3

Schematic illustration of a catheter-mounted VAD (a) Impella 2.5, CP, 5.0 and Thoratec PHP, (b) Impella LD

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Fig. 4

Placement of TandemHeart™ [35], photo courtesy of the Texas Heart Institute website.2 We acknowledge them for providing the photo.

Tables

Table Grahic Jump Location
Table 1 Examples of available continuous flow VADs
Table Footer NoteaPump type (A: axial, C: centrifugal, H: hybrid).
Table Footer NotebBearing type (M: magnetic, CB: contact bearing, PAM: passive and active magnetic, PM: passive magnetic, HD: hydrodynamic).
Table Footer NotecPump size (W: weight, V: volume).
Table Footer NotedPhotos courtesy of the manufacturer's website and brochures. We acknowledge them for providing the photos.
Table Grahic Jump Location
Table 2 Examples of available miniaturized catheter-based axial flow pump LVADs
Table Footer NoteaType of insertion (A: through the femoral artery, B: via open chest procedures, by way of the ascending aorta).
Table Footer NotebFrench catheter gauge.
Table Footer NotecPhotos courtesy of the manufacturer's website and brochures. We acknowledge them for providing the photos.

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