**4. Conclusions**

Recurrent HF is a very common complication after LVAD implant and portends a poor prognosis with increased morbidity and mortality. The causes are varied and identifying the correct etiology is critically important to proper management (**Figure 9**).

Given the highly specialized nature of many of these etiologies, it is recommended that HF in the LVAD patient be managed in an active LVAD center. A wealth of evidence exists defining the incidence and prevalence of LVAD-associated HF. However, only limited data are available to guide therapies.

In our opinion, future research to reduce morbidity associated with recurrent HF should focus on 3 major areas. (1) Preemptive strategies to prevent right HF: for instance, pre-LVAD temporary MCS usage has increased with time in the STS-INTERMACS database [8], but whether it will impact post-VAD outcomes remains to be determined. (2) Perioperative improvements and standardization of surgical methods: for instance, a meta-analysis of LVAD implant via lateral thoracotomy suggests a significantly lower incidence of post-LVAD right HF, an approach being tested in the ongoing SWIFT trial [106]. And, finally, (3) prospective assessment to identify treatment strategies that provide significant benefit for patients with recurrent HF. These could be pharmacologic strategies, or possibly development of durable RV support. Regardless, the breathtaking pace of LVAD technological development will no doubt continue to benefit patients with advanced HF.
