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Despite major advances in the treatment of heart failure over the past 2 decades improving the natural history of this condition, heart failure continues to be a major source of morbidity and mortality. Although availability of donor hearts for transplantation has declined over the past several years, innovations in ventricular assist device (VAD) technology has provided an alternative therapeutic option for patients with advanced heart failure. Initiated as a mechanical option to 'bridge' critically ill patients awaiting transplantation, VADs are being increasingly deployed as 'destination' devices to provide long-term support. With technical advances resulting in improved mechanical reliability, reduced postoperative morbidity and greater likelihood of patient acceptance, there is interest in expanding the applicability for destination VAD treatment beyond the current indication of severely ill patients who are not candidates for transplant. This Review examines the newer, third-generation VADs for mechanical cardiac support. These devices are at various stages of development and clinical investigation. One or more of these newer devices is likely to emerge as an important development in the treatment of patients with advanced heart failure.

Extracorporeal VADs are associated with higher mortality within 6 months and again beyond 5 years after transplantation. Intracorporeal VADs are associated with a small increase in mortality in the first 6 months and a clinically significant increase in mortality beyond 5 years. These data do not provide evidence supporting VAD implantation in stable United Network for Organ Sharing status I patients awaiting heart transplantation.

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Patients with sCVD are at an increased risk of stroke and functional decline after transplantation independent of other variables, but not death, during long-term follow-up. These results should assist programs in making informed decisions in patients with sCVD who are undergoing evaluation for heart transplantation.