Left Ventricular Assist Device as Destination Therapy: Surgical, Palliative, and End-of-Life Considerations. A Narrative Review

Durable left ventricular assist devices were introduced as an alternative to medical management for patients with advanced heart failure ineligible for transplantation.The original randomized evidence established a one-year survival benefit alongside a serious adverse event rate more than double that of medical therapy.Two decades later, a fully magnetically levitated centrifugal pump has produced overall survival of 58.4% at five years among patients still supported at two years, and pump replacement at two years was 2.3% with the centrifugal pump versus 11.3% with the axial-flow pump.This review examines what that change has meant for surgical practice and for the end of the treatment trajectory.The complication profile has shifted rather than disappeared: driveline infection, gastrointestinal bleeding, and stroke persist even as pump thrombosis has become uncommon, and right ventricular failure still complicates a fifth to a half of implantations, with published risk scores disagreeing on which preoperative variables predict it and none prospectively validated.Because survival on support is now measured in years, the surgical team increasingly implants a device into a patient who will die with it in place.Singleinstitution work shows that preimplantation palliative consultation and preparedness planning are feasible within the operative pathway, but also that documentation often fails to translate into device-specific advance directives.We argue that preparedness planning belongs to the preoperative pathway that surgeons control, propose clinical events that should trigger reassessment of goals of care, and set out the current framework for device deactivation together with its principal critics.