Relationship between bridging with ventricular assist device on rejection after heart transplantation.

BACKGROUND: Ventricular assist devices (VADs) are commonly used to bridge patients to heart transplantation. Recipients of VADs may develop anti-human histocompatibility leukocyte antigen antibodies, as reflected by elevated panel-reactive antibodies (PRA). The purpose of this study was to evaluate the relationship between bridging with VAD before heart transplantation and development of cellular rejection, humoral rejection, and allograft vasculopathy after transplantation. METHODS: Data on all patients who underwent cardiac transplantation between July 1994 and February 2001 at Rush Presbyterian St Luke's Medical Center were retrospectively reviewed. Data collected included sex, age, etiology of cardiomyopathy, percentage panel reactive antibodies (by cytotoxic method), type and duration of mechanical circulatory support, transfusion history, rejection history (both cellular and humoral) after cardiac transplantation, and development of allograft vasculopathy. Cellular rejection was treated when International Society of Heart and Lung and Transplantation Grade 2 or greater in the first 12 months after transplant and Grade 3 or greater after 12 months and treated with intensification of immunosuppression. Humoral rejection was defined clinically as allograft dysfunction by echocardiography without evidence of cellular rejection on endomyocardial biopsy or allograft vasculopathy. Allograft vasculopathy was defined by presence of any degree of luminal narrowing or pruning of distal vessels by coronary arteriography. Statistical analyses were performed by chi-square test, Fisher's exact test, and Wilcoxon rank sum test, as appropriate. RESULTS: Ninety-eight patients underwent cardiac transplantation during the study period (87 men, mean age 49 years, 46 ischemic etiology). Of these, 48 were bridged with HeartMate VAD (20 patients received vented electric device, 28 received pneumatic device). Nineteen percent of VAD patients had a peak pretransplant PRA > or =10% vs 2% of patients without VAD (p = 0.014). PRA > or =10%, use of VAD, or duration of VAD support did not predict development of humoral rejection. Use of VAD did not predict development of cellular rejection or allograft vasculopathy. VAD use was not associated with sudden death after heart transplantation. In the entire group of 98 patients, neither humoral nor cellular rejection predicted development of allograft vasculopathy. Longer ischemic time correlated with increased cellular rejection and humoral rejection after transplantation (p = 0.01). CONCLUSIONS: Some patients bridged to cardiac transplantation with VADs have increased PRA before heart transplantation, but this does not appear to translate into increased risk of either humoral or cellular rejection after transplantation or development of allograft vasculopathy as detected by coronary angiography.     

Pulsatile mechanical cardiac assistance in pediatric patients with the Berlin heart ventricular assist device

Mechanical cardiac assistance for neonates, infants, children and adolescents may be accomplished with pulsatile ventricular assist devices (VAD) instead of extracorporeal membrane oxygenation or centrifugal pumps. The Berlin Heart VAD consists of extracorporeal, pneumatically driven blood pumps for pulsatile univentricular or biventricular assistance for patients of all age groups. The blood pumps are heparin-coated. The stationary driving unit (IKUS) has the required enhanced compressor performance for pediatric pump sizes. The Berlin Heart VAD was used in a total number of 424 patients from 1987 to November 2001 at our institution. In 45 pediatric patients aged 2 days-17 years the Berlin Heart VAD was applied for long-term support (1-111 days, mean 20 days). There were three patient groups: Group I: "Bridge to transplantation" with various forms of cardiomyopathy (N = 21) or chronic stages of congenital heart disease (N = 9); Group II: "Rescue" in intractable heart failure after corrective surgery for congenital disease (N = 7) or in early graft failure after heart transplantation (N = 1); and Group III: "Acute myocarditis" (N = 7) as either bridge to transplantation or bridge to recovery. Seventeen patients were transplanted after support periods of between 4 and 111 days with 12 long-term survivors, having now survived for up to 10 years. Five patients (Groups I and III) were weaned from the system with four long-term survivors. In Group II only one patient survived after successful transplantation. Prolonged circulatory support with the Berlin Heart VAD is an effective method for bridging until cardiac recovery or transplantation in the pediatric age group. Extubation, mobilization, and enteral nutrition are possible. For long-term use, the Berlin Heart VAD offers advantages over centrifugal pumps and ECMO in respect to patient mobility and safety.     

Outcomes of Patients Undergoing Combined Heart–Kidney Transplantation With or Without Prior Ventricular Assist Device

BackgroundBoth combined heart–kidney transplantation and ventricular assist devices (VADs) pose significant challenges, including sensitization, immunosuppressive treatment, and infrastructure demands. Despite these challenges, we hypothesized that the recipients of combined heart–kidney transplants with and without VADs would have equivalent survival. We aimed to compare the survival of heart–kidney transplant recipients with and without prior VAD placement.MethodsWe retrospectively analyzed all patients enrolled in the United Network for Organ Sharing database who underwent heart–kidney transplants. We created a matched cohort of patients undergoing heart–kidney transplantation with or without prior VAD using 1:1 nearest propensity-score matching with preoperative variables.ResultsIn the propensity-matched cohort, 399 patients underwent heart–kidney transplantation with prior VAD, and 399 underwent heart–kidney transplantation without prior VAD. The estimated survival of heart-–kidney recipients with prior VAD was 84.8% at one year, 81.2% at 3 years, and 75.3% at 5 years. The estimated survival of heart–kidney recipients without prior VAD was 86.8.7% at one year, 84.0% at 3 years, and 78.8% at 5 years. There was no statistically significant difference in the survival of heart–kidney transplant recipients with or without prior VAD at one year (P = .42; Figure 2), 3 years (P = .34), or 5 years (P = .30).ConclusionDespite the increased challenge of heart–kidney transplantation in recipients with prior VAD, we demonstrated that these patients have similar survival to those who underwent heart–kidney transplantation without previous VAD placement.     

Ventricular assist device as a bridge to heart transplantation in adults

Background

Because of the shortage of donor hearts, various ventricular asist devices (VAD) have been used in decompensated patients to prolong patient survival until a suitable heart becomes available. In this paper, we present our single-center report of adult patients in whom bridging was used with VAD.

Methods

We performed a retrospective review of 14 adult patients who underwent heart transplantation after insertion of a long-term VAD. The study spans from February 2006 until September 2010. The mean patient age was 44.28 ± 11.06 years. We used the Berlin Heart EXCOR VADs (n = 11; Berlin Heart AG Berlin, Germany), or the Berlin Heart Incor (n = 2), or the Abiomed AB500 (n = 1). Preimplantation status of the subjects were critical cardiogenic shock (n = 6), deterioration on inotropes (n = 3), or stable but inotrope-dependent (n = 5).

Results

Mean VAD support time was 153.71 days (range, 25-517). Major adverse events during VAD support included reexploration for bleeding (n = 3; 21.4%), neurologic events (n = 2; 14.3%), left VAD-related infection (n = 2; 14.3%), pneumonia (n = 1; 14.3%), or primary device failure (n = 1; 7.1%). One (7.1%) patient showed evidence of human leukocyte antigen sensitization. There were 2 deaths (14.3%) over a mean of 324 days follow-up after heart transplantation: One due to biventricular failure in the early postoperative period and the other, at 69 days from pneumonia. Rejection was observed in 2 patients who had International Society for Heart and Lung Transplantation grade 2R without hemodynamic deterioration. In our series, the 1-year mortality was 14.4% among heart transplantations without VAD implantation and 14.2% among the bridge-to-transplantation group.

Conclusion

We conclude that VAD implantation improved end-organ function before heart transplantation in critically ill patients.     

Temporäre mechanische Kreislaufunterstützung bei Kindern und Patienten mit angeborenen Herzfehlern

Ventricular assist devices (VAD) in children with terminal heart failure have been used as a bridge to transplantation or myocardial recovery for more than 20 years. The Berlin Heart Excor® Pediatric VAD is approved for use either as univentricular or biventricular support for children with a body weight less than 20 kg. Larger children can be supported with implantable continuous flow devices, e.g. HeartWare HVAD. Indications for support are cardiomyopathy, myocarditis and terminal heart failure in patients with congenital heart diseases. Due to the shortage of donors support time on VADs has greatly increased often lasting longer than 1 year. Although increased experience and technical modifications over the last decade have substantially improved the outcome of patients on VAD support, much is still dependent on the etiology of the heart failure. The survival rate in children with normal anatomy is approximately 80?% compared to 50?% in children with congenital heart diseases. The main complications during VAD support which occur in nearly 25?% of children weighing less than 20 kg are thromboembolic events. Miniaturization of the device to improve the quality of life for children on support and minimizing the risk of thromboembolic events are current fields of intensive research.     

Ventricular assist device support in children and adolescents with heart failure: the Children's Medical Center of Dallas experience

Children with heart failure unresponsive to medical therapy are left with few options for survival. Ventricular assist devices (VADs) are life-saving options for such patients, allowing for bridge to transplantation or cardiac recovery. Retrospective review of cases from May 2006 to October 2010 was undertaken. Fourteen patients underwent implantation of VADs for refractory heart failure. Mean age was 9 years (range 1-17 years), and weight was 41 kg (range 9.7-71 kg). Indications for support: end-stage cardiomyopathy (n = 8), myocarditis (n = 3), univentricular failure (n = 2), and congenital heart disease/postcardiotomy (n = 1). Level of limitation at time of implant included critical cardiogenic shock in six (43%) and progressive decline in eight (57%). Extracorporeal membrane oxygenation was used as a bridge to VAD in five (36%) patients. Preimplant variables: 86% of patients requiring mechanical ventilation (mean 10.3 days), hyperbilirubinemia in 75%, and acute renal insufficiency in 79%. Device selection was systemic VAD in 11 (79%) and biventricular assist device in three (21%). Berlin Heart EXCOR was used in eight patients, while six patients received a Thoratec implantable VAD or paracorporeal VAD. Mean duration of support was 68 days (range 8-363 days). Overall survival was 79%. Ten patients (71%) were successfully bridged to transplantation, three (21%) died while on a device, one remains on support, and no patients were weaned from VAD. Children supported for single ventricle heart failure had a 50% survival with none currently bridged to transplantation. Complications included bleeding requiring reoperation in 21% (n = 3), stroke in 29% (n = 4), and driveline infections in 7% (n = 1). In two patients, a total of six pump exchanges were performed for thrombus formation. Survival for pediatric patients of all ages is excellent using current device technology with a majority of patients being successfully bridged to transplantation. Morbidity is acceptably low considering the severity of illness. Significant challenges exist with long-term extracorporeal support due to lack of donor availability and the high incidence of preformed alloantibodies especially in the failing single ventricle.     

Successful replacement of malfunctioning TCI HeartMate LVAD with DeBakey LVAD as a bridge to heart transplantation

Congestive heart failure is the leading cause of hospitalization and death in the developed world and affects about 0.4-2% of the adult population [Ann Thorac Surg 1999;68:637-40]. Heart transplantation remains the most effective therapy for end-stage heart disease, but the shortage of donors has led to increasing interest in other surgical options, especially ventricular assist devices (VAD). Several VADs are available to bridge patients to transplantation [N Engl J Med 2001;345:1435-43], including pulsatile devices like the HeartMate (HeartMate, Thoratec, Pleasanton, CA) and Novacor (World Heart, Netherlands), and the DeBakey VAD (MicroMed Technology, Inc., Houston, TX), which is an electromagnetically driven implantable titanium axial flow blood pump designed for left ventricular support. Despite technical improvements, VADs still are associated with serious complications. We reporte a successfull case where we replaced a TCI HeartMate with a DeBakey VAD because of a serious pocket infection, deterioration and failure of the inflow valve.     

Pediatric ventricular assist devices: Bridge to a new era of perioperative care

Pediatric ventricular assist devices (VADs) are evolving as a standard therapy for end stage heart failure in children. Major recent developments include the increased use of continuous flow (CF) devices in children and increased experience with congenital heart disease (CHD) and outpatient management. In the current and future era anesthesiologists will encounter more children presenting for VAD implantation, subsequent procedures and heart transplantation. Successful perioperative management requires an understanding of the interaction between the patient's physiology and the device and a framework to troubleshoot problems. This review focuses on CF devices, VAD support for CHD and perioperative management of pulsatile and CF devices in the pediatric population.     

Mechanical bridge with extracorporeal membrane oxygenation and ventricular assist device to heart transplantation

The aim of this study was to evaluate the effect of double bridges with extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) in clinical heart transplantation. Between May 1994 and October 2000, 134 patients underwent heart transplantation at the National Taiwan University Hospital. Ten patients received ECMO or VAD support as bridges to transplantation. The ages ranged from 3 to 63 years. The indications included cardiac arrest under cardiopulmonary resuscitation in 2 and profound cardiogenic shock refractory to conventional therapy in 8 patients. Usually ECMO was first set up as rescue therapy. If ECMO could not be weaned off after short-term (usually 1 week) support, suitable VADs (HeartMate or Thoratec VAD) were implanted for medium-term or long-term support. Five patients received ECMO support as emergency rescue for 2 to 9 days, and then moved to Thoratec VAD for 8, 49, and 55 days, respectively, or centrifugal VAD for 31 days, or HeartMate VAD for 224 days. They all survived. The survival rate of double bridges with ECMO and VAD was 100%. In postcardiotomy cardiogenic shock, circulatory collapse from acute myocardial infarction or myocarditis, ECMO is the device of choice for short-term support. If heart transplantation is indicated, VADs should replace ECMO for their superiority as a bridge to heart transplantation. Our preliminary data of double bridges with ECMO and VAD revealed good results and were reliable and effective bridges to transplantation.     

Mechanical circulatory support in severe heart failure: single-center experience

Ventricular assist devices (VADs) have become important therapeutic tools to treat patients with end-stage cardiac failure. VADs are an essential component of transplantation programs as they successfully bridge individuals who would otherwise die. Recently left ventricular VAD (LVAD) therapy has been proposed as alternative to heart transplantation (HTx) for patients who are not transplant candidates. Other indications have now expanded into areas such as postcardiotomy failure, acute myocarditis, and acute massive myocardial infarction. From 1988 to May 2003, 80 patients received left or biventricular mechanical circulatory support including 78 as a bridge to and two as an alternative to HT. All patients survived the operation. Mean duration of VAD support was 77 +/- 150 days. Fifty-one points (63.8%) underwent heart transplantation; 3 (3.8%) recovered and were weaned from VADs. Major bleeding episodes occurred in 11 patients (13.8%) and major neurologic events occurred in 8 (10%). Sixteen patients (20%) were discharged home while waiting for HTx. Twenty-two patients (27.5%) died on VAD. In conclusion, VAD therapy proved effective in bridging patients with end-stage heart failure to HTx. While on LVAD support patients who were assisted with implantable wearable devices could be discharged at home, improving their quality of life.     

Mechanical Circulatory Assistance in Children: Clinical Outcome

BackgroundIn countries where organ donation is scarce, mortality in the pediatric heart transplant waiting list is high, and ventricular assist devices (VADs) are therapeutic alternatives in these situations. Berlin Heart EXCOR is currently 1 of the few VADs specific for children.MethodsThis retrospective study includes pediatric patients who underwent Berlin Heart EXCOR placement in a Brazilian hospital between 2012 and 2021. Clinical and laboratory data at the time of VAD implantation and the occurrence of complications and outcomes (success as a bridge to transplant or death) were analyzed.ResultsEight patients, from 8 months to 15 years, were included: 6 with cardiomyopathy and 2 with congenital heart disease. Six were on Intermacs 1 and 2 on Intermacs 2. The most common complications observed were stroke and right ventricular dysfunction. Six were transplanted, and 2 died. Those submitted to transplant had a higher mean weight than those who died, with no statistically significant difference. The underlying disease had no impact on the outcome. The group undergoing transplant had lower brain natriuretic peptide and lactate values, but no laboratory variable showed a statistically significant difference in the outcome.ConclusionA VAD is an invasive treatment with potentially serious adverse effects and is still poorly available in Brazil. However, as a bridge to transplant, it is a useful treatment for children in progressive clinical decline. In this study, we did not observe any clinical or laboratory factor at the time of VAD implantation that implied better outcomes.     

Ventricular assist devices as a bridge to cardiac transplantation. A prelude to destination therapy.

OBJECTIVE AND BACKGROUND: Ventricular assist devices (VADs) have been used for temporary circulatory support pending transplantation or recovery of the native heart. Outcome in 38 patients treated at the authors' institution with VADs pending transplantation was analyzed to provide information relevant to the future use of VADs as permanent implants. METHODS: Thoratec (Thoratec Laboratories, Pleasanton, CA) or HeartMate (Thermo Cardiosystems, Woburn, MA) VADs were used in all cases. Patients were considered for VAD placement if they were candidates for cardiac transplantation and fulfilled the criteria for the Food and Drug Administration investigational Device Exemption trials. The following adverse events were included in the analysis; death during VAD support, device malfunction, bleeding, neurologic events, support-related events that preclude transplantation, and device-related infections. Patient survival and complication rates were quantified using the Kaplan-Meier method, competing risk analysis, and hazard functions. RESULTS: Nineteen patients had transplantation. Three patients had VAD removal after cardiac recovery and 16 died without transplantation. The duration of VAD support ranged from 0 to 279 days. The hazard function for death during VAD support had an early phase that lasted for 2 weeks after VAD placement, and early death was related to the preimplant condition of the patient. Device-related infections were noted in 11 patients. Seven of these patients had transplantation after clearing the infection, whereas four died without transplantation. Neurologic events occurred in seven patients. There were no device malfunctions that led to patient death. CONCLUSIONS: The absence of fatal device malfunctions suggests that longer term support with current VAD designs is feasible. Appropriate patient selection, infection control, and avoidance of thromboembolic neurologic complications will be crucial to the success of permanent VAD use.     

Multiple splenic infarctions due to septic embolization in a patient supported with Berlin Heart-EXCOR biventricular assist device

Patients awaiting cardiac transplantation often require ventricular assist devices (VADs) due to instable circulatory condition. Device-related infections remain the 'Achilles heel' of mechanical circulatory support and wound complications after VAD placement are a formidable challenge to surgeons. Up to 25% of deaths in VAD patients are due to systemic sepsis, which occurs in 11-26% of patients and bacteria that are common pathogens including Staphylococcus, Pseudomonas, Enterococcus, and Candida. Sepsis, infection of implanted pump components, and infections of percutaneous drivelines continue to limit survival. The Berlin Heart-EXCOR VAD is a para-corporeal pulsatile system that has been successful in patients with severe biventricular dysfunction. We report a case of a 35-year-old male suffering from a postischemic cardiomyopathy who received an EXCOR biventricular assist device as a bridge to transplant. During the assistance the patient developed concomitant methicillin-resistant Staphylococcus aureus infection of implanted pump components which was resistant to conventional therapy. The patient developed sepsis with splenic infarctions due to septic embolization which was successfully treated with a heart transplant. In some extreme cases of VAD infections, such as this, the only therapeutic option is transplantation or device replacement.     

Cardiopulmonary transplantation

The Registry of the International Society for Heart and Lung Transplantation reported 108,034 adult recipients of deceased donor heart transplants between January 1992 and June 2018. The 37th annual adult lung transplant report submitted data to the ISHLT TTX Registry on 67,493 adult recipients of deceased donor transplants between January 1, 1992 and June 30, 2018. In recent years more than 5000 heart transplants and approximately 4000 lung transplants have been performed annually across 388 centres worldwide. Heart transplantation is a proven surgical option for selected patients with advanced heart failure refractory to surgical or medical management. Lung transplantation is the definitive treatment for end-stage lung disease in patients who have failed medical therapy. More than 90% of adult patients presenting for heart transplantation have dilated cardiomyopathy or ischaemic cardiomyopathy. Anaesthetic principles for heart transplantation comprise full monitoring, including transoesophageal echocardiography, cardiostable anaesthesia and cardiac support with assessment and treatment of pulmonary vascular hypertension. Median survival after cardiac transplantation is 11.9 years. Lung transplantation includes single-lung, double-lung, bilateral sequential single-lung, heart–lung and lobar transplantation. The most common indication, representing more than one-third of all transplant recipients, is chronic obstructive pulmonary disease. Donor criteria have become more liberal and lung transplants may involve cardiopulmonary bypass. Pre-bypass air trapping can compromise cardiac function. Postoperative ventilation management should be guided by pH, not P_aCO₂. Thoracic epidural analgesia provides optimal pain relief without respiratory depression. Five-year survival after lung transplantation is approximately 65%.     

The expanding role of ventricular assist devices in the management of end-stage heart failure

Rapid advances in the medical treatment of congestive cardiac failure have improved both the quality of life and life expectancy. However end-stage heart failure poses immense challenges to the clinician. Cardiac transplantation has been the mainstay of treatment for a small group of patients who can no longer be managed effectively with therapeutic agents. Unfortunately the limited donor pool restricts the number of patients who can be offered this treatment. Mechanical devices for circulatory support have been proposed to bridge patients to a successful transplant, and more ambitiously have been proposed as an alternative to transplantation. There has been a profusion of new devices using different technologies, but all remain limited by the biological–mechanical interface. There are significant economic considerations if the technology is to be available to everyone with heart failure. This article reviews the history of ventricular support, indications, outcome data and practical advice on management of the patient with the VAD from the pre-operative phase to discharge into the community.     

Cost comparison of heart transplant vs. left ventricular assist device therapy at one year

With the worldwide shortage of donor organs, use of ventricular assist device (VAD) therapy is rapidly increasing in both the bridge to transplant and destination therapy settings. However, the high cost of VADs and VAD care is a cause for concern for policy makers who have relied on the limited supply of donor hearts to naturally cap health expenditure on heart transplantation (HTx). We sought to compare costs of the first 12 months of care of VADs vs. HTx. Single center retrospective study utilizing real generated costs over a three yr span from 2010–2012. Only patients with 12 months of costing data were included. Costs of 28 HTx patients and 24 VAD patients were analyzed. Index admission costs were more than double in the VAD group compared to the HTx group and this was driven by the procurement costs and length of stay which increased almost all aspects of in hospital care costs. Subsequent costs were six times higher in the HTx group and this was driven largely by pharmaceuticals. VAD therapy remains a very expensive treatment option for end stage heart failure patients. Device prices need to reduce substantially to make this a more widely applicable and cost effective treatment option.     

Berlin Heart ventricular assist device in a child with hypoplastic left heart syndrome

We report the implantation of a Berlin Heart ventricular assist device (VAD) in a 4-year-old boy with hypoplastic left heart syndrome previously palliated with Norwood and Glenn operations, who presented with progressive ventricular failure and hypoxemia. Insertion of a 30-mL pneumatic pediatric pump with cannulation of the systemic right ventricle and aorta had a salutary effect on cardiac output, improving oxygen saturations. While awaiting heart transplantation, multiple thromboembolic complications developed and he died, despite therapeutic heparinization and aspirin therapy. Important lessons learned about VAD support in Glenn physiology, anticoagulation, and complications of the Berlin Heart are discussed.     

Mechanical Support and Medical Therapy Reverse Heart Failure in Infants and Children

Most infants and children implanted with ventricular assist devices (VADs) go on to cardiac transplantation. Recovery of dilated cardiomyopathies with the combination left ventricular decompression with a VAD and treatment with maximal medical therapy has been possible in some adults, and may be more feasible in infants and children. We used pulsatile and continuous flow VADs and the total artificial heart (TAH) as bridges to transplantation or to recovery. Candidates for native heart recovery were treated with maximal medical therapy for congestive heart failure and short‐term dobutamine prior to weaning off device support. Since 1997, 28 infants and children, ages 1 month to 16 years, were implanted for durations of 3–107 days (mean 27). Eighteen received left VADs (LVAD), seven biventricular assist devices (BiVADs), and three TAHs. Device‐related mortality was 7/28 (25%), leaving 21/28 (75%) surviving to transplantation or weaning from device support and 20/28 (71%) discharged from the hospital and currently surviving for 2 months to 9 years. Ten of 11 transplant recipients (90%) have survived 2 to 9 years. All 10 with recovered hearts are alive and well for 2 months to 5 years. Eight of 12 (67%) LVAD patients with dilated hearts recovered. None of the recovery patients were over 6 years old. Infants and children who have failed inotropic therapy may be treated with an LVAD and medical therapy for congestive heart failure anticipating native heart recovery. A variety of devices have been tried. All small LVADs yielded comparable results. Larger and older children also have a chance of recovery, but our experience with them is too small except to note that they do well with larger devices and transplantation.     

Mechanical heart support at the Deutsches Herzzentrum Berlin: Recent developments (2011)

Since the inception of the mechanical circulatory support (MCS) program at the Deutsches Herzzentrum Berlin (DHZB) in 1987, more than 1600 patients have received support with 18 different designs of technical blood pump systems, in accordance with the respective state of the art. At the beginning, pulsatile pneumatic extracorporeal ventricular assist devices (VAD) and implantable pneumatic total artificial hearts (TAH) were available, followed by pulsatile electromechanical implantable devices. At this time the assist program was based on three objectives: bridging to recovery, bridging to heart transplantation (HTx) and for permanent support. Very soon (in 1995) patients of advanced age – over 65 years – were included in the program. In 1998 rotary blood pumps with continuous flow entered the program, from 2006 edging out step by step the pulsatile systems. Today the implantable pulsatile systems have disappeared from the DHZB program, with the exception of the extracorporeal uni‐ or biventricular pneumatic EXCOR systems (Berlin Heart GmbH), which are the only systems available for newborns and children. The only approved total artificial heart is the CardioWest device, implanted in rare cases after explantation of the natural heart. Miniaturized rotary blood pumps, axial flow turbines or centrifugal radial flow pumps are leading today's market. The size and configuration of one of these pumps, the hydrodynamically and magnetically levitated HeartWare HVAD, allowed its application as a biventricular implantable assist device. The worldwide first clinical implantation of this system was performed at the DHZB in 2009. With the increasing number of patients needing immediate circulatory support and the stagnating or even decreasing number of donor hearts available for HTx, the extreme discrepancy means that other therapies are gaining increasing importance. The objectives of the MCS program therefore had to focus on permanent VADs, thus creating a growing population of long‐term outpatients with implanted systems, living with their families a near‐normal life. Within a quarter century VAD implantation has grown from an experimental procedure into an established and generally accepted therapy. Facing the rapidly increasing population of patients with end‐stage heart failure and the stagnating number of heart transplants, the use of VAD technology may represent the most advanced progress in cardiac care in the coming years. Further minaturization of the devices will allow the treatment of patients with a wide age spectrum, from newborn children to the elderly, even with biventricular support. The ultimate goal will be the development of a durable total artificial heart, based on the rotary blood pump technology, with transcutaneous energy transfer through the intact skin, guaranteeing the patients optimal quality of life for many years of support.