Long-term continuous-flow left ventricular assist devices have become a real alternative to heart transplantation in patients with advanced heart failure, achieving a promising 2-year event-free survival rate with new-generation devices. Currently, this technology has spread throughout the world, and any cardiologist or cardiac surgeon should be familiar with its fundamentals and its possible complications as well as the advances made in recent years. The aim of this review is to describe current knowledge, management of complications, and future directions of this novel heart-failure therapy. Long-term continuous-flow left ventricular assist devices have become a real alternative to heart transplantation in patients with advanced heart failure, achieving a promising 2-year event-free survival rate with new-generation devices. Currently, this technology has spread throughout the world, and any cardiologist or cardiac surgeon should be familiar with its fundamentals and its possible complications as well as the advances made in recent years. The aim of this review is to describe current knowledge, management of complications, and future directions of this novel heart-failure therapy.

Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients.

The information on heart transplantation (HT) in patients with Friedreich’s Ataxia (FA) is scarce, and the few published case reports are limited to young patients with mild neurological manifestations. We present the case of a 58-year-old patient with advanced FA (Scale for the Assessment and Rating of Ataxia [SARA] score 30/40), wheelchair-bound for the last 16 years and had urinary incontinence, dysarthria, and neurosensorial deafness. The patient was admitted for a refractory arrhythmic storm and had previous hypertrophic cardiomyopathy that evolved to dilated cardiomyopathy with severely reduced left ventricular ejection fraction and recurrent ventricular arrhythmias. A multidisciplinary team discussed the HT option. The patient was aware of the risks and benefits and considered worthy of the intervention, so he was listed for HT. After a successful surgical intervention, the patient had a long postoperative stay in ICU. He required a high dose of vasopressors, underwent hemofiltration for one month, suffered critical illness myopathy, had several respiratory infections and delayed tracheal extubation. Two and a half months after HT and almost five months at the hospital, the patient was successfully discharged. FA patients with severe heart conditions should be carefully evaluated by a multidisciplinary team to decide the candidacy for HT.

Heart transplantation (HT) is the gold standard therapy for advanced heart failure (ADHF), and LVADs as destination therapy are an option in non-HT candidates. Most patients with ADHF never receive HT or an LVAD, so alternative strategies are needed. Intermittent levosimendan can reduce HF hospitalizations in ADHF patients in the short term. It is uncertain whether the results of the comparison of inotropes with older-generation LVADs would have the same outcomes in the current era of ADHF patients treated with levosimendan, who are less sick but older. In this paper, we compare the use of two therapeutic strategies for end-stage HF in patients who are not candidates for HT: repetitive intermittent levosimendan vs. LVAD as destination therapy. To do so, we compare two multicenter cohorts of real-life patients from Spain: the LEVO-D registry and the REGALAD registry. In total, 715 patients coming from the two registries were found: 403 from LEVO-D and 312 from REGALAD. Non-adjusted median survival was shorter for LEVO-D patients, with the benefit for the LVADs seen only after the first year of therapy. The survival advantage for the LVAD cohort was also true after analysis of the matched cohort but, as in the non-matched analysis, the survival benefit was mainly shown after one year of follow-up. We conclude that in elderly ADHF non-HT candidates, LVAD therapy offers significantly better long-term outcomes when compared to intermittent levosimendan; thus, it should be considered in carefully selected candidates. On the other hand, in poor LVAD candidates or highly comorbid patients, intermittent inotropic support with levosimendan could be a reasonable alternative to LVAD, as 1-year outcomes are similar.

Aims: Arrhythmic burden after discharge in patients with new-onset persistent left bundle branch block (NOP-LBBB) following transcatheter aortic valve replacement (TAVR) with Evolut devices remains largely unknown. The aim of this study is to assess the incidence and type of arrhythmias at 2-year follow-up in patients with NOP-LBBB post-TAVR. Methods and results: This is a prospective multicentre study including 88 patients with LBBB persisting for ≥3 days post-implantation. Before discharge, an implantable loop recorder (REVEAL XT/LINQ) was implanted; patients had continuous monitoring for 2 years. Arrhythmic events were adjudicated in a central core lab. Of the arrhythmic events, 411 were detected in 58 patients [65.9%; 2 (1–4) events per patient]. Symptoms were reported in 12/58 (20.7%), and therapy was changed in 25/58 (43.1%). There were 101 bradyarrhythmic events in 33 patients [35 high-grade atrioventricular block (HAVB) and 66 severe bradycardia]. The HAVB incidence was higher in the early (4-week) phase and remained stable over time, whereas severe bradycardia increased after 1 year. Permanent pacemaker was required in 11 (12.5%) patients (6.8% and 5.7% in the first and second year, respectively). There were 310 tachyarrhythmic events in 29 patients (120 AF/AFL, 111 AT, 72 SVT, 6 NSVT, and 1 VT); its incidence decreased throughout the 2 years. New AF/AFL episodes occurred in 20/69 patients [29%; symptomatic in 2/20 (10%)]. Conclusion: Patients with NOP-LBBB post-TAVR with Evolut devices exhibited a high burden of late arrhythmias, with events occurring in two-thirds of patients and leading to treatment changes in about half of them. These data should inform future studies on cardiac monitoring devices for follow-up and treatment optimization in this challenging population.