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The ongoing quest for the first total artificial heart as destination therapy

Abstract

Many patients with end-stage heart disease die because of the scarcity of donor hearts. A total artificial heart (TAH), an implantable machine that replaces the heart, has so far been successfully used in over 1,700 patients as a temporary life-saving technology for bridging to heart transplantation. However, after more than six decades of research on TAHs, a TAH that is suitable for destination therapy is not yet available. High complication rates, bulky devices, poor durability, poor biocompatibility and low patient quality of life are some of the major drawbacks of current TAH devices that must be addressed before TAHs can be used as a destination therapy. Quickly emerging innovations in battery technology, wireless energy transmission, biocompatible materials and soft robotics are providing a promising opportunity for TAH development and might help to solve the drawbacks of current TAHs. In this Review, we describe the milestones in the history of TAH research and reflect on lessons learned during TAH development. We summarize the differences in the working mechanisms of these devices, discuss the next generation of TAHs and highlight emerging technologies that will promote TAH development in the coming decade. Finally, we present current challenges and future perspectives for the field.

Key points

  • After decades of research on total artificial hearts, only two devices are clinically available as a bridge to transplantation therapy; a total artificial heart suitable for destination therapy has not yet been developed.

  • Currently available total artificial hearts have major drawbacks, including bulkiness, limited durability, poor biocompatibility, high complication rates and low quality of life for the recipients.

  • We are on the verge of an era in total artificial heart development in which rapidly evolving technologies from different fields will lead to new approaches in total artificial heart design and development.

  • More powerful and more compact batteries and transcutaneous energy transfer systems will omit the need for percutaneous cables and will improve the quality of life of the recipients of a total artificial heart.

  • With the rise of soft robotic technologies and smart biomaterials, completely soft total artificial hearts might soon be developed and are likely to have fewer biocompatibility issues than current devices.

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Fig. 1: Timeline of the milestones in the development of total artificial hearts.
Fig. 2: Working mechanisms for different types of total artificial hearts.
Fig. 3: Efficiency of total artificial hearts.

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Acknowledgements

The authors are grateful to L. C. van Laake (AMOLF, Netherlands), D. Zrinscak (Scuola Superiore Sant’Anna, Italy) and A. Henseler (evos GmbH, Germany) for their contributions and discussions; D. van Urk (Amsterdam UMC, The Netherlands) for assisting with screening and selecting articles; T. Azami (Amsterdam UMC, The Netherlands) and C. M. van de Beek (Amsterdam UMC, The Netherlands) for assistance with data extraction; C. E. J. M. Limpens (Amsterdam UMC, The Netherlands) and A. Malekzadeh (Amsterdam UMC, The Netherlands) for their help with the literature search; and ReinHeart TAH GmbH, Germany for providing additional data upon request. The authors’ work is part of the HybridHeart project and is funded by the European Union Horizon 2020 research and innovation programme under grant agreement no. 767195.

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A.V. and M.A. did the major literature search and wrote the first draft. All of the authors contributed to the discussion of content and reviewed and edited the manuscript before submission.

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Correspondence to Jolanda Kluin.

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A.V., M.A., H.K., J.T.B.O. and J.K. are part of the HybridHeart consortium. The other authors declare no competing interests.

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Glossary

Driveline

Percutaneous cable that transmits electrical power from an external driver to the internally implanted device such as a TAH or LVAD.

Transcutaneous energy transfer (TET) system

A wireless power delivery system that uses magnetic fields to transfer power across the skin without the need for direct electrical connectivity.

Bronchial shunt

The physiological passage of oxygenated blood from the aorta to the bronchial circulation. This blood returns directly to the left atrium, thereby bypassing the right side of the heart.

Frank–Starling mechanism

This law states that the stroke volume of the heart increases in response to an increase in the volume of blood in the ventricles before contraction (the end diastolic volume), when all other factors remain constant.

Preload

The filling pressure of the ventricle at the end of diastole, which is determined by the atrial pressure.

Stator

The stationary part of a rotary machine or device.

Investigational device exemption

Type of FDA approval that allows the investigational device to be used in a clinical study in order to collect safety and efficacy data.

Afterload

The amount of pressure that the ventricle needs to exert to eject the blood during ventricular contraction.

Biofunctionalization

The modification of a material to add a biological function, such as replace or repair, while at the same time being accepted by the host organism.

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Vis, A., Arfaee, M., Khambati, H. et al. The ongoing quest for the first total artificial heart as destination therapy. Nat Rev Cardiol (2022). https://doi.org/10.1038/s41569-022-00723-8

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