Mechanical circulatory support: state of the art and future perspectives.

Mechanical circulatory support (MCS) has been viewed, until recently, as a rescue therapy to be applied when all else fails. Not surprisingly, this has resulted in suboptimal outcomes. Fortunately, the perseverance of a few dedicated groups has produced improved outcomes and the concept of MCS as an elective therapy is now steadily gaining acceptance. This is particularly true in the postcardiotomy setting, where a large number of new options are now available. The recently completed REMATCH study has demonstrated the feasibility and efficacy of permanent MCS as a therapy for end-stage heart failure, despite a high rate of device complications. Donor availability is decreasing and biological solutions will not be available for many years. New generation implantable rotary pumps, a fully implantable left ventricular assist device and a total artificial heart are all undergoing clinical evaluation, and several new exciting designs are in preclinical evaluation. A new paradigm for the treatment of terminal heart failure is emerging, where an unpredictable and expensive medically managed death in an intensive care unit setting is being exchanged for a more predictable high-cost, front-loaded therapy with management from the outpatient clinic. The perfusionist community has much to contribute to this emerging life support field, not only in the perioperative period, but also in providing ongoing technical support to hospital staff, recipients and their families.