Ventricular assist devices: destination therapy or just another stop on the road?

Ventricular assist devices have attained center-stage recognition with the evolution of the concept of destination therapy, designed as an alternative to cardiac transplantation. However, mechanically induced hemodynamic restoration is accompanied by cellular and biochemical effects that may potentially mediate cardiac recovery. This has raised the fundamental question of whether mechanical assistance is a "failure to grave" option or simply a stop on the road to recovery. The concept of destination therapy as an alternative to transplantation was validated in the Randomized Evaluation of Mechanical Assistance in the Treatment of Congestive Heart Failure trial, but gaps in translating this information to the clinical realm exist because of device limitations of complications and durability. The field of mechanical assistance is progressing rapidly with the introduction of smaller devices that are more durable and have less risk for infection or hematologic aberrancies, which should allow this option to meaningfully enter the clinical arena.