History and Application of Mechanical Assist Devices as a Bridge to Heart Transplant: A Review and Perspectives in Brazil.

Mechanical circulatory support (MCS) devices have evolved significantly over the past decades and play a vital role in managing end-stage heart failure, especially as a bridge to heart transplantation. From the pioneering heart-lung machines to third-generation ventricular assist devices (VADs), MCS technology has advanced to provide more durable, efficient, and safer options for both shortand long-term support. This review outlines the historical development of mechanical assist devices, the types of available supports - ranging from intra-aortic balloon pumps and extracorporeal membrane oxygenation to implantable devices like HeartMate 3 - and their clinical indications and complications. Special attention is given to right ventricular dysfunction, thromboembolic and hemorrhagic complications, and infections, which remain major challenges in the management of patients with MCS devices.In Brazil, despite the growing evidence supporting MCS in critically ill patients, access remains limited due to financial and systemic constraints. The review explores the current landscape of device availability in the country, national guidelines, cost-effectiveness data, and the impact of recent changes in transplant allocation criteria that prioritize patients receiving mechanical support. Notably, the approval of long-term VADs for destination therapy in the public health system in 2024 marks a significant milestone.This review offers a comprehensive perspective on MCS utilization, highlighting both global advances and Brazil-specific challenges. By identifying gaps in access and proposing future directions, it advocates for expanded use of these life-saving technologies to improve survival and quality of life in advanced heart failure patients.