Total Artificial Heart: Procedure, Benefits, Risks, Recovery and Alternatives

The total artificial heart (TAH) is a remarkable innovation in advanced heart failure management, offering hope for patients facing end-stage biventricular failure where conventional therapies are no longer an option. This comprehensive article explores the TAH procedure, its benefits and effectiveness, potential risks, the recovery process, and alternatives, synthesizing the latest scientific evidence and real-world clinical experiences.

Total Artificial Heart: The Procedure

When someone’s heart can no longer effectively pump blood due to severe failure in both ventricles, a total artificial heart may be considered. The TAH replaces the failing heart’s lower chambers and valves with a mechanical system that restores circulation and offers a bridge to transplantation or, in select cases, a longer-term solution. The procedure is intricate, requiring specialized surgical expertise and advanced technology.

Step	Description	Purpose	Source(s)
Assessment	Comprehensive evaluation of patient status	Identify candidates	1 2 7 11
Surgery	Removal of native ventricles/valves, implant TAH	Restore circulation	1 2 3 8 12
Device Types	Pneumatic, electric, bioprosthetic	Suit patient needs	4 5 9 12
Goals	Bridge-to-transplant, destination therapy	Survival/recovery	1 2 12

Table 1: The Total Artificial Heart Procedure

Patient Selection and Assessment

Before implantation, patients undergo a thorough evaluation to confirm irreversible biventricular heart failure and to exclude other options like ventricular assist devices (VADs). Candidates are often critically ill, with life-threatening heart failure unresponsive to other treatments. Many are already on maximal medical therapy and require mechanical ventilation or other life support measures 1 2 7 11.

Surgical Implantation

The TAH procedure involves:

• General anesthesia and opening the chest
• Removal of both native ventricles and all four heart valves
• Sewing the TAH into place, connecting it to the atria and great vessels
• Attachment to an external driver that powers and controls the device (although fully implantable models are being developed) 1 2 3 8 12

Different TAH models exist:

• SynCardia/CardioWest: Pneumatically driven, widely used as a bridge to transplant
• AbioCor: First fully implantable TAH, though no longer in clinical use due to limited success
• CARMAT: Electrohydraulic, uses bioprosthetic materials for improved compatibility; still under investigation
• ReinHeart: Electrically driven, fully implantable, designed to minimize wear and improve quality of life (not yet in routine clinical use) 4 5 9 12

Procedural Goals

The TAH’s main purposes are:

• Bridge to transplantation: Keeping patients alive and stable until a suitable donor heart becomes available
• Destination therapy: For those ineligible for transplant, providing longer-term circulatory support 1 2 12

Benefits and Effectiveness of Total Artificial Heart

The TAH has transformed outcomes for patients with otherwise fatal biventricular failure. Its ability to fully replace both ventricles and all heart valves makes it uniquely effective in specific, high-risk populations.

Benefit	Outcome/Statistic	Patient Impact	Source(s)
Bridge-to-Tx	68–79% survive to transplant	Increased survival	1 2 8 11
Post-Tx Survival	1-year: 70–90%; 5-year: 60–76%	Long-term benefit	1 2 8
End-organ Recovery	Improved renal, hepatic, and nutritional status	Better transplant candidacy	1 10
Expanded Access	For patients not eligible for VADs or with congenital heart disease	More options	2 10

Table 2: Benefits and Effectiveness of Total Artificial Heart

Improved Survival

TAH implantation significantly boosts the chances of surviving to heart transplantation compared to historical controls. Studies show survival rates to transplant of 68–79% for TAH patients, compared to 46% for those managed without it 1 2 8 11. Post-transplant, one-year survival rates reach up to 90%, with five-year survival of 60–76% 1 2 8.

End-Organ and Functional Recovery

Replacing both ventricles relieves congestion and restores blood flow, allowing for recovery of organs such as the kidneys and liver. Nutritional and physical rehabilitation becomes possible, making patients better candidates for transplant 1 10. This is especially important for those with multi-organ dysfunction at the time of TAH implantation.

Unique Patient Populations

• Contraindication to VADs: Patients ineligible for left ventricular assist device (LVAD) therapy due to right heart failure may benefit from TAH 2.
• Congenital Heart Disease/Adolescents: TAHs like SynCardia and AbioCor have provided options for adolescents and adults with complex congenital heart disease, who previously had few or no alternatives 10.

Expanded Device Capabilities

Innovations include:

• Smaller devices for smaller patients and children
• Fully implantable systems (under investigation) that may improve quality of life and reduce infection risks 5 10 12

Risks and Side Effects of Total Artificial Heart

Despite its life-saving potential, TAH therapy is associated with significant risks due to the device itself, the complexity of surgery, and the fragile health of recipients.

Risk	Frequency/Severity	Impact	Source(s)
Multi-organ failure	Major cause of death on support	High mortality	2 6 8
Stroke	7–8% during support	Neurologic deficit	2 8 11
Infection	Occurs in 35–85% during support	Prolonged recovery	8 9 11
Bleeding	25% require re-operation for hemorrhage	Surgical risk	2 3 8

Table 3: Major Risks and Side Effects of Total Artificial Heart

Surgical and Early Postoperative Risks

• Hemorrhage: Significant bleeding during or after surgery is common, sometimes requiring additional operations 2 3 8.
• Infection: Device-related or systemic infections are a frequent complication, particularly due to percutaneous lines or immunosuppression 8 9 11.
• Stroke: Neurologic events occur in up to 8% of patients, with potential for long-term disability 2 8 11.

Device-Related Complications

• Thrombosis and Embolism: Though rare with improved designs and anticoagulation, these can cause stroke or device malfunction 9.
• Mechanical Failure: While rare, device malfunction can be fatal; durability is a focus of newer devices 5 12.
• Hemolysis: Destruction of red blood cells can occur but is minimized with modern bioprosthetic and soft pumps 4 9.

Late and Systemic Complications

• Multi-Organ Failure: Often related to the patient’s preoperative condition; remains a leading cause of death on support 2 6 8.
• Renal and Respiratory Failure: Both can complicate recovery, especially in patients with pre-existing organ dysfunction 3 11.
• Quality of Life Limitations: External drivers and equipment can restrict mobility and independence, though fully implantable systems may change this in the future 5 12.

Recovery and Aftercare of Total Artificial Heart

Recovery after TAH implantation is complex. Patients require intensive monitoring, rehabilitation, and adaptation to life with a mechanical heart.

Aspect	Focus	Goal/Outcome	Source(s)
ICU Care	Hemodynamic support, infection control	Stabilization	2 3 6 11
Rehabilitation	Physical, nutritional, organ recovery	Transplant candidacy	1 10
Device Management	Anticoagulation, equipment training	Prevent complications	2 9 12
Transition	Home support (select cases/devices)	Improved quality of life	9 10 12

Table 4: Recovery and Aftercare Elements

Intensive Postoperative Care

Immediately after surgery, patients typically remain in the ICU for:

• Hemodynamic monitoring
• Management of bleeding, infection, and organ function
• Titration of anticoagulation to prevent clots and strokes 2 3 6 11

Rehabilitation and Organ Recovery

• Physical Therapy: To regain strength after critical illness
• Nutritional Support: Optimizes recovery and immune function
• Renal and Hepatic Monitoring: Ensures recovery of end-organs, which is crucial for transplant eligibility 1 10

Device Education and Management

• Anticoagulation: Careful management is essential to prevent clots or bleeding 2 9
• Equipment Training: Patients and caregivers learn how to manage external drivers, alarms, and emergencies
• Transition to Home: Select patients (with certain devices and adequate support) may be discharged home while awaiting transplant or as destination therapy, improving independence and quality of life 9 10 12

Long-term Follow-up

• Regular assessments for device function, infection, and organ status
• Coordination with transplant teams or, for destination therapy, ongoing monitoring for device and patient well-being

Alternatives of Total Artificial Heart

While the TAH is a powerful tool for end-stage biventricular failure, it is not suitable for everyone. Several alternatives exist, each with its own indications, benefits, and limitations.

Alternative	Indication / Suitability	Key Features	Source(s)
LVAD/BiVAD	Isolated or predominant left (or both) ventricular failure	Less invasive, partial support	2 6 7
Medical Therapy	Early or palliative-stage heart failure	Symptom management	1 2 6
Transplantation	Eligible candidates, with donor heart available	Curative potential	1 2
Newer TAH Designs	Suitable for smaller patients, destination therapy	Improved mobility	5 9 10 12

Table 5: Alternatives to Total Artificial Heart

Ventricular Assist Devices (VADs)

• LVAD: Supports only the left ventricle; less invasive than TAH; unsuitable in severe right heart failure
• BiVAD: Supports both ventricles using two separate devices; considered when both sides are compromised but TAH is not feasible 2 6 7

Medical Management

• For patients not eligible for device therapy or transplant, medical options aim to relieve symptoms and improve quality of life, but do not alter the disease course 1 2 6.

Heart Transplantation

• Remains the gold standard for eligible patients; limited by donor availability
• TAH serves as a bridge to transplant for those at risk of dying before a donor heart is found 1 2

Emerging and Future Alternatives

• Miniaturized TAHs: Designed for smaller patients, including children 5 10
• Fully Implantable Systems: May reduce infection risk and improve lifestyle 5 9 12
• Next-Generation Devices: Research continues into soft, bioprosthetic, or more durable systems 4 5 9 12

Conclusion

The total artificial heart represents a dramatic advance in the treatment of end-stage biventricular heart failure, offering hope to those once considered beyond help. Here’s a summary of key points covered:

• TAH fully replaces both ventricles and all heart valves, restoring circulation in critically ill patients.
• The procedure is most often used as a bridge to transplantation, but can also serve as destination therapy for select patients.
• Survival rates to transplantation and beyond are significantly improved, with notable recovery of end-organ function.
• Risks include bleeding, infection, stroke, and multi-organ failure, highlighting the need for careful selection and postoperative care.
• Recovery involves ICU care, rehabilitation, meticulous device management, and, in some cases, transition to home.
• Alternatives such as VADs, medical therapy, and transplantation remain important; continuous innovation is expanding options for more patients.

The total artificial heart continues to evolve, promising even greater benefits as technology, device design, and patient care advance. For those facing the most severe forms of heart failure, it offers not just a second chance at life, but a bridge to new possibilities.