Left ventricular assist devices as long-term mechanical circulatory support are increasingly utilized as an option for medically refractory advanced heart failure. Rapid advances in this field, from pulsatile paracorporeal flow pumps to now more advanced intracorporeal continuous flow devices, have led to more wide spread use of device therapy. Several trials have now confirmed the survival benefits of ventricular assist devices, not only as a method for bridging patients waiting on the transplant list, but also as an evolving paradigm of destination therapy. Significant improvements in quality of life and functional status have been reported in patients receiving these devices. Survival outcomes with this therapy continue to improve, and long term durability of newer generation devices remains yet to be discerned. Comparative data to heart transplantation remains scarce. This paper will focus on the historical development of ventricular assist device therapy for advanced heart failure, review major trials of destination therapy, and look at comparative literature in the modern era to cardiac transplantation. 1. Introduction Left ventricular assist devices (LVAD) as long term mechanical circulatory support (MCS) therapy are being used with increasing frequency for medically refractory heart failure. Over 4000 patients in the United States have received LVAD implants, and this number continues to grow [1]. Technological advancements have rapidly advanced this field, with the replacement of pulsatile paracorporeal flow pumps with intracorporeal continuous flow devices. Several trials have now confirmed the survival benefits of LVAD therapy, not only as a method for bridging patients waiting on the transplant list, but also as an evolving paradigm of destination therapy (DT) [2]. Significant improvements in quality of life and functional status have now been reported in patients receiving these devices [3]. This review will focus on the historical development of LVADs, review major trials of LVAD use as destination therapy, and look at comparative literature in the modern era to cardiac transplantation. 2. History The development of MCS support has evolved over time. Work on engineering designs on LVAD therapy as long term support began in the late 1960s, and after several years of trialed designs, the first HeartMate IP LVAS system was approved for use in the United States in 1994. The first generation LVADs produced pulsatile flow and simulated cyclic stroke volume with normal physiologic blood pressure and pulse. Among these devices, the WorldHeart
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