Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Mechanical circulatory support and heart transplantation
Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Time-critical presentation
Refractory cardiogenic shock, recurrent arrest/VT-VF, low-flow LVAD alarm with hypoperfusion, suspected pump thrombosis or major LVAD bleeding requires immediate resuscitation and contact with the implanting/advanced-HF centre; device patients may have no palpable pulse despite circulation.
Purpose and principles
Recognise advanced-heart-failure referral triggers, match temporary or durable support to a bridge goal and understand the UK specialist pathway to transplantation.
Mechanical support is not a single treatment. Temporary devices stabilise a potentially recoverable or undecided patient; durable LVAD and transplant require a lengthy assessment of end-organ reversibility, RV function, frailty, adherence and goals.
Timing determines eligibility. Referral after repeated shock, severe cachexia or irreversible renal/hepatic injury may be too late even when the cardiac indication is obvious.
UK access is concentrated in commissioned specialist centres. A non-implanting hospital's first task is early centre-to-centre discussion, safe stabilisation and transfer—not independent device selection.
Key points
Refer advanced HF early: recurrent admission, escalating diuretic, prior inotrope, NYHA III–IV despite therapy, low BP, worsening renal/liver function, severe RV dysfunction or ventricular arrhythmia are red flags.
Every device needs a bridge goal: recovery, intervention, decision, candidacy, transplantation or long-term support; reassess that goal daily in temporary MCS.
An intra-aortic balloon pump modestly augments coronary perfusion; a microaxial LV pump unloads the LV; VA-ECMO supplies circulation plus gas exchange but may increase LV afterload; an RVAD supports isolated RV failure.
Indications, selection and cautions
Advanced-HF referral marker
Prior inotrope, NYHA III–IV, very low EF, end-organ decline, ICD shock, repeated admission, refractory oedema, low BP or inability to tolerate prognostic medicines should prompt early centre referral.
Refractory shockRed flag
Rising lactate, escalating vasoactive support and multi-organ injury despite cause treatment may require temporary MCS before irreversibility.
LVAD low-flow emergencyRed flag
Alarm plus dizziness, confusion, dyspnoea or low perfusion may reflect hypovolaemia, RV failure, tamponade, arrhythmia, hypertension, obstruction or pump thrombosis.
Pump thrombosis/haemolysisRed flag
New power/flow abnormality, dark urine, raised LDH, falling haemoglobin or HF symptoms needs immediate implant-centre assessment.
Driveline or device infectionRed flag
Exit-site pain, erythema, discharge, fever or bacteraemia can seed the device and requires cultures and specialist treatment.
Transplant complicationRed flag
New dyspnoea, fatigue, graft dysfunction, arrhythmia, fever or biomarker change may indicate rejection, infection or allograft vasculopathy; symptoms can be subtle in a denervated heart.
Confirm severity, RV function, reversibility and referral urgency.
Interpretation and limitations
Use the whole trajectory; no single EF or prognostic score should gate referral.
02Cardiopulmonary exercise testing and 6-minute walk
Why
Objectify limitation and transplant/LVAD risk where the patient is stable enough.
Interpretation and limitations
Interpret peak VO2 with age, sex, effort and beta-blockade; it supports but does not replace MDT judgement.
03Right-heart catheterisation
Why
Measure output, filling pressures and pulmonary vascular resistance before advanced therapy.
Interpretation and limitations
Potentially irreversible pulmonary vascular disease can preclude isolated heart transplant; repeat after optimisation when reversibility is uncertain.
04MCS surveillance labs
Why
Detect haemolysis, bleeding, thrombosis, infection and organ injury.
Interpretation and limitations
Trend haemoglobin, platelets, LDH/haemolysis markers, coagulation/anticoagulation, renal/liver function and cultures with device parameters.
05
Treatment approach
01First-lineEarly advanced-HF referralFirst stepFirst lineOne or more advanced-HF red flags despite guideline-directed therapy+
1Refer to an advanced-HF/transplant centre while optimising four-class therapy, rhythm, CRT/ICD, valve/coronary disease, congestion, iron and rehabilitation.
2Send the trajectory: admissions, inotrope/diuretic exposure, BP, renal/liver function, RV/LV imaging, arrhythmia and functional status.
3Begin shared discussion of transplant, durable LVAD, expected burdens, palliative options and patient goals.
4Correct reversible barriers such as infection, smoking/substance use, nutrition, adherence support and incomplete cancer screening through the centre pathway.
02Second-lineTemporary MCSSecond linePotentially reversible or bridgeable shock failing conventional treatment+
MCS complications: access/limb perfusion, bleeding, haemoglobin/platelets, anticoagulation, LDH/haemolysis, thrombosis, infection and organ function.
Durable LVAD: daily driveline site, controller/power and alarm checks plus centre-specified INR/anticoagulation; never apply generic targets across devices.
Advanced-HF waitlist: symptoms, admissions, BP, arrhythmia, renal/liver function, nutrition/frailty and changes affecting urgency or suitability.
Post-transplant: centre-specified drug levels, renal/liver/metabolic profile, blood count, infection and rejection/allograft-vasculopathy surveillance.
Patient and caregiver competence, psychosocial strain, rehabilitation and emergency contact/transfer plan.
Special situations
Bridge language changes decisions
A device without a stated destination can prolong harm; name recovery, intervention, decision, candidacy, transplant or long-term support.
No pulse may be normal
Continuous-flow LVAD patients may have little palpable pulse or automated BP reading; assess consciousness, breathing, capnography/Doppler and device function while calling the centre.
VA-ECMO is not LV unloading
It supplies flow and oxygenation but can increase LV afterload and pulmonary congestion, prompting specialist unloading strategies.
Waiting list is a matching system
NHSBT prioritises urgency, blood group, donor-recipient size, antibodies and geography before waiting time.
Referral does not commit
Early advanced-HF referral creates options and shared decisions; it does not automatically mean implant or transplant.
Common pitfalls
01
Waiting for irreversible end-organ failure before referring a repeatedly admitted advanced-HF patient.
02
Choosing a device by availability rather than failing ventricle, oxygenation need, contraindications and bridge goal.
03
Assuming NICE procedural guidance means universal NHS commissioning for every MCS indication.
04
Changing LVAD speed or disconnecting both power sources without the implant centre.
05
Treating transplant listing as first-come-first-served or ignoring psychosocial/adherence and infection assessment.
Practice
Two practice questions
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Question 1 of 2
0 correct
CardiologyOriginal SBA
When to refer
A 54-year-old with HFrEF has two admissions in six months, escalating loop-diuretic doses, SBP 88–92 mmHg and worsening renal function despite specialist optimisation. What is the best next step?
Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·
NICE 2025 advises MDT patient selection and specialist-centre delivery for VA-ECMO in severe acute HF; efficacy varies and serious complications are common.
NICE 2026 permits catheter-based microaxial LV pump use for cardiogenic shock only in PPCI centres with on-site intensive-care expertise and special evidence/governance arrangements.
NHS England commissions specialist VAD services as bridges to transplantation, candidacy or recovery; availability of long-term destination use is not assumed and requires the national specialist commissioning route.
Heart transplantation is for selected advanced HF after optimisation and multidisciplinary assessment of benefit, comorbidity, infection/malignancy, pulmonary vascular resistance, adherence and psychosocial support.
LVAD complications include bleeding, thrombosis/stroke, infection, haemolysis, arrhythmia, aortic regurgitation and RV failure; transplant adds rejection, infection, malignancy and immunosuppressant toxicity.
Compare with the patient's usual settings and contact the implant centre; never change speed empirically without specialist direction.
06Transplant work-up and surveillance
Why
Assess infection, malignancy, vascular/immunological compatibility and later rejection/allograft vasculopathy.
Interpretation and limitations
Tests and biopsy/imaging schedules are transplant-centre protocols; an organ offer depends on urgency, blood group, size, antibodies and geography, not waiting time alone.
1Activate the regional shock/MCS centre and define LV, RV, biventricular and oxygenation needs plus neurological/end-organ prognosis.
2Choose support matched to physiology and bridge goal; secure consent/governance or emergency best-interest process.
3Treat the cause and monitor bleeding, limb ischaemia, haemolysis, thrombosis, infection, LV distension and device flows continuously.
4EscalationReassess daily for recovery/weaning, escalation to durable support/transplant or transition in goals.
03Third-lineDurable LVAD assessmentThird lineAdvanced HFrEF not recovering with an appropriate bridge indication+
2Confirm the NHS commissioned indication—typically bridge to transplant, candidacy or recovery—and discuss that device care is lifelong and centre-linked.
3Provide anticoagulation/bleeding, driveline, power, alarm and emergency education with backup equipment before discharge.
4Continue rehabilitation and surveillance for RV failure, stroke, thrombosis, infection, haemolysis, GI bleeding and aortic regurgitation.
04EscalationTransplant listing and follow-upEscalationEligible advanced HF after transplant-centre MDT assessment+
1Complete immunological, infectious, malignancy, pulmonary vascular, renal/hepatic and psychosocial evaluation and obtain informed consent.
2List by the national urgency category and matching system; reassess fitness while waiting and notify the centre of admission or clinical change.
3After transplant, use centre-directed immunosuppression, rejection/infection surveillance, vaccination and allograft-vasculopathy prevention.
4Provide long-term rehabilitation, cancer/renal/metabolic screening and rapid access for fever or graft dysfunction.