The Evolution and Current State of Left Ventricular Assist Device Technology: A Review of Clinical, Computational, and Experimental Studies on Commercial and Research Devices

Abstract

Heart failure (HF) remains a leading global health burden, with a subset of patients requiring advanced interventions beyond optimal medical therapy. Left ventricular assist devices (LVADs) have emerged as a critical treatment option for patients with end-stage HF, serving either as a bridge to transplantation or as destination therapy. This narrative review explores the evolution, clinical application, engineering development, and future outlook of LVAD technology through clinical, computational, and experimental lenses. Mechanical circulatory support originated in the mid-20th century with the advent of cardiopulmonary bypass. Early pulsatile LVADs (e.g., HeartMate I, Thoratec) improved hemodynamics but were plagued by infections, thrombosis, and mechanical failures. The REMATCH trial demonstrated survival advantages but highlighted design limitations. The second generation introduced continuous-flow axial pumps like HeartMate II and Jarvik 2000, offering enhanced durability and reduced infection risk but introducing complications from non-physiologic flow, including gastrointestinal bleeding and acquired von Willebrand syndrome. Third-generation centrifugal-flow devices, notably HeartMate 3 with magnetically levitated impellers, improved hemocompatibility and durability. MOMENTUM 3 trial results favored HeartMate 3, showing markedly lower pump thrombosis (0.6% vs. 12.5%) and stroke (2.8% vs. 11.3%) rates compared to HeartMate II. Nonetheless, complications persist. Right ventricular failure occurs in up to 25% of recipients, often requiring RVAD support. Aortic insufficiency arises in over 30% within two years due to commissural fusion. Stroke and driveline infections remain concerns, although improved designs have reduced thromboembolic events. Engineering advancements—especially computational fluid dynamics (CFD), finite element analysis (FEA), and mock circulatory models—have informed iterative design improvements and anticoagulation strategies. AI and machine learning are being explored for predictive monitoring and automated control of pump function. Economic evaluations, such as the UK ICER analysis (£47,361 per QALY for HeartMate 3), support LVAD use in select patients but underscore ongoing cost-effectiveness concerns. Looking forward, priorities include fully implantable systems, wireless power transmission, enhanced biomaterials, and integration with tissue-engineered constructs. Optimizing patient selection and minimizing complications through the synergy of clinical, computational, and engineering innovations will be pivotal in expanding the benefits of LVAD therapy.