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Left Ventricular Assist Devices

Michael S. Mulvihill, MD

Assistant Professor of Surgery

Division of Cardiothoracic Surgery

University of Minnesota

8 January, 2026

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Disclosures

  • No financial disclosures

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  • Discussions of the following includes the off-label use of otherwise approved devices

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Topic Overview – Mechanical Circulatory Support

  • Temporary vs Durable – shock vs end-stage heart failure

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  • Left sided, right sided, and biventricular support

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  • Bridges and exit strategies

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Temporary Support & Cardiogenic Shock

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  • Clinical trial definitions generally have 4 elements
    • Hypotension (SBP < 90 for ≥30 minutes or use of circulatory support)
    • Preload adequacy (congestion or wedge ≥ 15)
    • Low cardiac output (CI ≤ 1.8 L/min/m2)
    • Hypoperfusion (oliguria < 30 mL/h, serum lactate > 2.0mmol/L)

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  • Further granularity to severity as discussed previously
  • Cardiogenic shock as a final common pathway for multiple acute cardiovascular causes
    • Acute myocardial infarction
    • Acute heart failure
    • Myocarditis
    • Post-cardiotomy

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Goals

  • Rapid identification, early resuscitation, and multidisciplinary management of the population
  • Improve clinical outcomes by supporting cardiac output, reducing tissue hypoxemia, resolving systemic hypoperfusion, and ultimately mitigating end-organ dysfunction
  • Successfully manage short-term situation in order to properly ascertain appropriate long-term management strategies
  • “door to support” decisions

Shock team outcomes summarized by Moghaddam et al (2021)

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Planning & Considerations

  • All responses can be characterized based on context, specificity, and magnitude (Allan Kirk)

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  • Timing and team familiarity
  • Location & Setting
  • Projected duration of support
  • Goals and destination considerations

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Overview of Temporary Mechanical Support Strategies

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Percutaneous

Surgical

Left-Sided Support

IABP (femoral, axillary)

Impella CP

TandemHeart (LA-Ao)

IABP (axillary graft)

Impella 5.5 (axillary graft)

Impella 5.5 (direct aortic)

LV CentriMag (LV apex)

Right-Sided Support

Impella Flex V

TandemHeart (RA-PA)

ProtekDuo/Spectrum RVAD (RA-PA)

RV CentriMag (RV / RA-PA)

Biventricular Support

Peripheral VA ECMO

Impella CP + Flex V or Protek

Central cannulation VA ECMO

Axillary cannulation ECMO (Axillary / IJ)

Biventricular CentriMag

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L Sided Support

  • Percutaneous Devices
    • IABP – femoral or axillary (percutaneous or open)
    • Impella
    • TandemHeart

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  • Surgically-Placed Devices
    • IABP – axillary graft
    • Axillary 5.5 – axillary graft or direct aortic
    • CentriMag

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L Sided Support - Impella

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DanGer Shock and Impella Support

2013-2023, enrolled 360 patients – 18 and older with STEMI and cardiogenic shock (SBP < 100), arterial lactate ≥2.5, LVEF ≤ 45%.

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Patients who had been resuscitated from OOHCA and remained comatose on arrival and those with overt RV failure were excluded

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R sided Support

  • Protek and Spectrum Cannulas with RVAD
    • Single stage, dual-lumen cannula, with or without an oxygenator
  • Impella RP Flex
    • Micro-axial flow pump
  • TandemHeart
  • Surgical CentriMag (RA-PA)

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Biventricular Support

  • Percutaneous / Peripheral ECMO
  • Central and hybrid (axillary + femoral) ECMO
  • Biventricular CentriMag
  • Dual-percutaneous options

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Biventricular Support - ECMO

  • Modification of cardiopulmonary bypass with centrifugal pump and membrane oxygenator

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  • > 5L flow
  • Permits weeks of support
  • Higher levels of anticoagulation
  • Ambulation may depend on cannulation strategies
  • Time to support variable depending on cannulation strategies

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Via ELSO

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Biventricular Support - CentriMag

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  • Extracorporeal ventricular assist via centrifugal flow pump
  • Left, right, or biventricular configurations (RA-PA, LA/LV-Ao, both)
  • Formally approved for 30 days of use
  • >5L maximal support

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Summary Considerations – Temporary Support

  • The goal of mechanical circulatory support remains to improve clinical outcomes by supporting cardiac output, reducing tissue hypoxemia, resolving systemic hypoperfusion, and ultimately mitigating end-organ dysfunction
  • Permits appropriate long-term management strategies
  • A team-based approach with regular contact and diverse input likely ensures the best chance that patients are matched with an optimal management strategy

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Indications and Options for Durable Support

  • Total Artificial Heart (TAH)
  • Left Ventricular Assist Devices (LVAD)

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  • Indications
    • NYHA IV Symptoms
    • EF < 25%
    • Inotrope dependent or CI < 2.2 L/min/m2 with one of:
    • ADHF for ≥14 days and dependent on IABP/tMCS ≥7 days or
    • Failed OMM for at least 45 of last 60 days

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Heart Failure Classification

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Heart Transplant Volume – United States

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Heart Failure - Unmet Needs

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Cooley first implantation of a total artificial heart, 1969

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Total Artificial Heart

  • Dual LVAD in RVAD and LVAD configurations (“HeartMate 6”)
  • Syncardia TAH
  • BiVACOR
    • Investigational use – early feasibility
  • CARMAT
    • Investigational use
    • 3 patients 2021
    • Second cohort beginning

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Total Artificial Heart - Syncardia

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Total Artificial Heart - Syncardia

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Total Artificial Heart - BiVACOR

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Total Artificial Heart - CARMAT

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Brief Aside – BrioVAD

  • Currently enrolling in INNOVATE - pivotal phase clinical trial
  • Safety phase completed
  • Non-inferiority trial designed to compare to Abbott Heartmate III

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Heart Mate III - 2 Year Outcomes

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Heart Mate III - 2 Year Outcomes – Momentum III

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Heart Mate III - 2 Year Outcomes – Intermacs

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Heart Mate III - 2 Year Outcomes – Intermacs

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Heart Mate III – Survival by Intermacs Profile

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HeartMate 3 – 5 Year Outcomes

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HeartMate 3 – 5 Year Outcomes

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HeartMate 3 – 5 Year Outcomes

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HeartMate 3 – 5 Year Outcomes

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HeartMate 3 – 5 Year Outcomes – Overall Survival

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HeartMate 3 – 5 Year Outcomes – Survival by Age

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HeartMate 3 – 5 Year Outcomes – Stroke

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HeartMate 3 – 5 Year Outcomes – Pump Thrombosis

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Durable LVAD Recommendations

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LVAD Quality of Life

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Over 30,000 patients have been implanted with �the HeartMate 3™ LVAD*

  • MORE THAN 19,000 PATIENTS RECEIVE ONGOING SUPPORT

13,047

19,580

8,648

5,279

2,692

1,257

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439

MAT-2002006 v13.0 | Item approved for U.S. use only.

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0

0

0

0

0

0

0

0

0

0

0

The above numbers are cumulative. Patients with a duration of > 2 years are included in the number of patients listed as > 1 year.

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Thank you!

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Michael Mulvihill, M.D.

University of Minnesota

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mmulvihi@umn.edu

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