Current Role of the Total Artificial Heart in the Management of Advanced Heart Failure

Abstract

The total artificial heart (TAH) is a form of mechanical circulatory support that involves resection of the native ventricles followed by placement of a device that can restore total pulmonary and systemic flow. Given the increasing burden of congestive heart failure and cardiovascular disease, the number of people in need of cardiac replacement therapy will continue to grow. Despite aggressive efforts to expand the donor pool, the number of heart transplants in the United States (US) has plateaued at less than 3000 per year. In addition, there is increasing recognition of the long-term complications of current generation left ventricular assist devices such as progressive aortic insufficiency, complications related to blood trauma, and both early and delayed right ventricular failure. These factors may serve to expand the role of the TAH in the treatment of patients with end-stage heart failure particularly if new generation devices are developed that are durable, have an improved safety profile, and are totally implantable. PURPOSE OF REVIEW: To review the role and current evidence of the use of the TAH in the management of advanced heart failure and discuss development of recent TAHs that may have an impact on the field in the near future. RECENT FINDINGS: Many patients that receive a heart transplant are bridged with a mechanical support device, most commonly a left ventricular assist device (LVAD). However, there is a small subset of patients with profound biventricular (BV) failure or structural abnormalities that preclude LVAD placement, who will require support with a biventricular assist device (BiVAD) or TAH. There are numerous studies showing the efficacy of the TAH in bridging to transplantation. Also, recent studies have shown equal rates of bridging to transplantation between patients receiving a TAH compared to a BiVAD. However, BiVAD support has a higher incidence of stroke in addition to complications related to the native heart such as arrhythmias and valve dysfunction. Currently, there are multiple new generation artificial hearts in both preclinical development and in clinical trials for both bridge to transplant and destination therapy. TAH have been shown to be effective for circulatory support in select patients with end-stage heart failure. Current LVADs are associated with significant long-term complications related to retention of the native heart and pump design. Many of these complications may be addressed by the increased use of cardiac replacement therapy, i.e., total artificial hearts. Multiple generations of both pulsatile and advanced design continuous flow TAH are under development which have the potential to expand the role of TAHs.

Keywords: Advanced heart failure; Biventricular circulatory support; Bridge to heart transplantation; Mechanical circulatory support; Total artificial heart.