Current aspects in surgical treatment of advanced heart failure with future durable mechanical circulatory support.

Background Cardiovascular disease remains the leading cause of death worldwide, resulting in an increasing demand for long-term treatment options for patients with end-stage heart failure. While heart transplantation is the gold standard, donor organ shortage continues to be a major limitation, particularly in countries with opt-in consent systems. Summary Durable mechanical circulatory support (dMCS) devices have emerged as a critical therapy for patients with advanced heart failure, either as a bridge to transplantation or as destination therapy. Technological innovations over recent decades have transitioned from pulsatile to continuous-flow systems, with the HeartMate 3 currently representing the only long-term left ventricular support, due to its superior hemocompatibility, clinical outcomes, and full magnetic levitation. However, limitations persist, especially regarding right-sided and biventricular support, driveline infections, and patient quality of life. This review provides a comprehensive overview of both currently approved and investigational dMCS devices, highlighting key engineering features, hemocompatibility advancements, and the status of ongoing clinical trials. Emerging devices such as the Corheart 6, BrioVAD, EvaHeart 2, CorWave, FlowMaker, and TorVAD aim to enhance physiologic support, minimize shear stress, and enable full implantability. Additionally, novel concepts for biventricular and total heart replacement, including BerlinHeart Excor, reBEAT, DuoCor BiVAS, SynCardia, Emperor and BiVACOR are discussed. Key Messages •HeartMate 3 remains the only approved LVAD in Europe following HVAD withdrawal. •Next-generation devices aim to improve hemocompatibility, reduce complications, and support full implantability. •Options for biventricular or right heart failure remain limited, but novel concepts are emerging.