Keeping left ventricular assist device acceleration on track.

Almost 50 years ago, the National Heart, Lung, and Blood Institute launched the journey of mechanical circulatory support. These pioneers have included innovative engineers, cardiac surgeons, and stalwart patients accompanied by devoted families, who together have led us to a horizon where widespread clinical utilization is finally within sight. The pace of progress is always slower than projected. Despite our impatience, we should not rush too far beyond the light of the wagons onto terrain that is less hospitable to medical technological advances than it was 50 years ago. Since the approval of a continuous-flow destination device in January 2010, there has already been a 10-fold increase in the implantation of left ventricular assist devices (LVADs) for lifetime support, the major avenue for expansion of circulatory support. We would join advocates for more systematic evaluation of lifetime ventricular assist device (VAD) therapy in the patients listed with high priority for transplantation (a small population) and ambulatory patients with class IV symptoms (a population of unknown size and comorbidities). It is our position, however, that the current basis of evidence for selection and management of patients with LVAD does not support more aggressive acceleration of LVAD utilization than is already underway.