On Target

The use of mechanical circulatory support for patients with advanced heart failure has increased exponentially within the past 10 years. Durable left ventricular assist devices (LVADs) in particular have changed the treatment paradigm for medically refractory heart failure, with an evolution in patient selection from those tethered to the hospital bed with inotrope support as a bridge to transplant, to those with earlier stage disease, and for use as destination devices for those not eligible for heart transplant. Interagency Registry for Mechanically Assisted Circulatory Support has registered more than 15 000 patients implanted with Food and Drug Administration–approved devices since the creation of the program in 2006.1 LVADs not only prolong life but have been shown to improve the quality of life and the functional capacity of patients.2 Many factors are responsible for the explosion in use and improved outcomes. Remarkable improvements in device design and technology, including smaller device size and better power supply, have lead to easier placement and improved patient acceptance. The engineered changes in pump flow mechanisms and component materials, however, with the shift from pulsatile to continuous-flow pumps, represent the most dramatic change.See Article by Nassif et al Despite the technological advances in LVADs and the overall improvement in life expectancy, serious complications persist. The 2 major complications—thrombosis and bleeding—are the result of the inherent prothrombotic nature of the artificial surfaces in contact with the blood and the requirement for mandatory anticoagulation to prevent thrombosis. Bleeding events comprise the highest adverse events. Interagency Registry for Mechanically Assisted Circulatory Support reports a bleeding rate of 9.41 events per 100 patient-months in the first year after implantation during the time period 2008 to 2011, with a subsequent decrease to 7.79 events per 100 patient-months during 2012 to 2014.2 During these 2 time periods, as …