Letter regarding the article ‘Are mechanical circulatory supports the forgotten aspect in the implementation of therapies for heart failure?’

Abstract

Baudry and colleagues reported trends in durable mechanical circulatory support (MCS), primarily left ventricular assist devices (LVADs), across Europe from 2018 to 2023.¹ They highlighted the underutilization of durable MCS, despite heart failure (HF) remaining a leading cause of mortality. Their hypotheses—improvements in medical therapies, referral delays to advanced HF units, the COVID-19 pandemic, and changes in graft allocation—are valid. However, the period from 2018 to 2023 cannot be considered a single therapeutic era, as significant advancements in HF with reduced ejection fraction (HFrEF), including sodium–glucose cotransporter 2 inhibitors and vericiguat (in some countries), were only implemented in 2022.²

We commend the authors for this unprecedent analysis but would like to offer a more optimistic perspective. Since 2022, durable MCS including LVADs and Aeson® total artificial hearts (TAHs) have been gaining traction in Europe. LVAD implantations increased across most countries between 2022 and 2023, from +2% in Austria to +25% in the Czech Republic and Germany, and + 51% in Poland. Though France initially lagged, it is showing strong momentum in 2024 with 118 LVADs (matching 2023's total) and forecasts of 165 LVADs by the end of the year. Additionally, 45 Aeson® TAH devices have been implanted across Europe since the programme resumed in November 2022, primarily in France, Germany, and Italy. Once again, France leads the way with 20 TAHs already implanted and a projection of 30 by the end of the year.

Awareness is growing that death from HF is no longer inevitable and that durable MCS is an accessible, life-saving therapy. First, clinicians recognize that despite optimal medical management, one in five HFrEF patients progresses to advanced HF and may require durable MCS.³ Second, improved communication within the cardiology community has increased acceptance of durable MCS. The rise in advanced HF sessions at congresses and a growing body of scientific publications reflect this trend. As expertise grows in implantation, device optimization, and long-term management, physicians are more confident in highlighting the benefits of durable MCS rather than focusing on its drawbacks.

More physicians now regard durable MCS as an option for life. The European ELEVATE registry has been instructive, providing real-world data easily translatable to clinical practice showing a 5-year survival rate of 63% with LVAD, alongside significant improvements in functional capacity and quality of life.⁴ In parallel, physicians are gradually recognizing that durable MCS and heart transplant are complementary, not competing. Durable MCS is a valuable bridge to transplant for critically ill INTERMACS 1–2 patients, provides crucial rehabilitation and family time for INTERMACS 3–4 patients at limited access to transplant. It also provides an alternative for those with contraindications including age, pulmonary hypertension, obesity. Finally, public awareness campaigns at local and national levels are crucial in demystifying, destigmatizing and promoting durable MCS.

The revolution is underway. Let us make it our revolution.