Pulmonary hypertension (PH) represents a critical barrier in the selection of candidates for heart transplantation, significantly influencing post-transplant outcomes and patient survival. Defined by elevated pulmonary arterial pressure, PH complicates the management of patients with end-stage heart disease, necessitating innovative therapeutic strategies to improve their prognosis and transplant eligibility.1 Mechanical circulatory support (MCS) devices, particularly left ventricular assist devices (LVADs), have emerged as pivotal interventions for patients with fixed PH, offering a potential bridge to transplantation.2

The pathophysiological impact of PH in heart transplant candidates is profound, as it is associated with increased perioperative risk and heightened mortality post-transplantation.3 The selection of heart transplant candidates thus mandates a careful evaluation of PH, with an emphasis on distinguishing between reversible and fixed forms of the condition.4 Reversible PH can often be managed with medical therapies; however, fixed PH presents a more daunting challenge, necessitating more aggressive interventions like MCS.5

LVADs, a subset of MCS devices, have shown particular promise in this context. These devices not only provide hemodynamic support but also have a direct impact on the pulmonary vasculature, potentially reversing the pulmonary vascular remodeling associated with PH.6 Studies have demonstrated that the implantation of LVADs can lead to a significant reduction in pulmonary vascular resistance (PVR), thereby converting patients with fixed PH into viable transplant candidates.7

Despite these advancements, the heterogeneity of MCS devices and their mechanisms of action necessitates a nuanced understanding of their efficacy. While continuous flow LVADs have been the focus of much research, other MCS modalities warrant consideration to delineate their specific roles in managing PH in the transplant setting.8 Furthermore, the timing of intervention, patient selection criteria, and the impact of MCS on long-term outcomes remain areas of active investigation.9

An overview of the various MCS devices currently in use, including LVADs, is presented in Table 1. This table details the types of devices, their descriptions, rates of implementation, and key features that have evolved over time with the advancement of technology.

The evolution of MCS technology and its integration into the management of heart transplant candidates underscore the dynamic nature of this field. As devices evolve and new data emerge, it is imperative to continually reassess and refine treatment protocols to optimize patient outcomes.10 This systematic review aims to synthesize current evidence on the effectiveness of MCS devices in reversing fixed PH among heart transplant candidates, providing insights that can guide clinical practice and future research.