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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Mechanical circulatory support and heart transplantation

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

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.

Synopsis

Recognise advanced-heart-failure referral triggers, match temporary or durable support to a bridge goal and understand the UK specialist pathway to transplantation.

  • 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.
  • 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.

Key red flags

Refractory shock

Rising lactate, escalating vasoactive support and multi-organ injury despite cause treatment may require temporary MCS before irreversibility.

LVAD low-flow emergency

Alarm plus dizziness, confusion, dyspnoea or low perfusion may reflect hypovolaemia, RV failure, tamponade, arrhythmia, hypertension, obstruction or pump thrombosis.

Pump thrombosis/haemolysis

New power/flow abnormality, dark urine, raised LDH, falling haemoglobin or HF symptoms needs immediate implant-centre assessment.

Driveline or device infection

Exit-site pain, erythema, discharge, fever or bacteraemia can seed the device and requires cultures and specialist treatment.

Transplant complication

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.

Investigation priorities

01
Advanced-HF assessment: echo, ECG, natriuretic peptide, renal/liver/haematology and functional testingFirst step

Confirm severity, RV function, reversibility and referral urgency.

Management branches

First-lineEarly advanced-HF referral

One or more advanced-HF red flags despite guideline-directed therapy

  1. Refer to an advanced-HF/transplant centre while optimising four-class therapy, rhythm, CRT/ICD, valve/coronary disease, congestion, iron and rehabilitation.
  2. Send the trajectory: admissions, inotrope/diuretic exposure, BP, renal/liver function, RV/LV imaging, arrhythmia and functional status.
  3. Begin shared discussion of transplant, durable LVAD, expected burdens, palliative options and patient goals.
  4. Correct reversible barriers such as infection, smoking/substance use, nutrition, adherence support and incomplete cancer screening through the centre pathway.
Open full textbook →Answer 2 questionsCardiology check
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.

  • NICE NG106: Chronic heart failure in adultsAdvanced-HF MDT, transplant and device route.
  • NICE HTG764: VA-ECMO for severe acute heart failureOctober 2025 selection, specialist-centre and governance guidance.
  • NICE HTG775: LV microaxial flow pump for cardiogenic shockMarch 2026 evidence-generation and centre requirements.
  • NHS England: Cardiac specialised servicesCommissioned transplant and VAD service routes.
  • NHS Blood and Transplant: How heart offering worksUK urgency and matching principles.
  • ESC 2021 Guidelines for acute and chronic heart failureAdvanced-HF and MCS framework.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom