3 The procedure
3.1 'Destination therapy' is a term that refers to the implantation of a left ventricular assist device (LVAD) with the aim of providing permanent circulatory support to people with advanced heart failure who are ineligible for heart transplantation. This guidance is based on evidence from studies in which the intended treatment strategy was destination therapy, and not bridge‑to‑transplantation.
3.2 The LVAD is implanted with the patient under general anaesthesia and involves open heart surgery, usually with cardiopulmonary bypass. Initially, the pump component of the LVAD is placed in the pericardium. An inflow pipe is then inserted into the left side of the heart (usually the left ventricle) and an outflow pipe is inserted into the systemic arterial system (usually the aorta). Subsequently, a power cable, attached to the pump, is brought out of the abdominal wall to the outside of the body and attached to a control system and battery. Once the pump begins to work and support the heart, the cardiopulmonary bypass machine is removed and the chest incision is closed. The LVAD draws oxygenated blood from the failing left ventricle and pumps it into the systemic arterial system under pressure.
3.3 The first LVADs used pulsatile pumps that mimicked the natural pulsing action of the heart. Newer, more commonly used, devices use a rapidly spinning rotor to produce a continuous flow of blood into the systemic arterial system. Some people may also need simultaneous implantation of a second device to support right ventricular function.