**Conflict of interest**

between the patient and their carers, the clinicians and local emergency and social services. Well thought through protocols taking into account the geographic particularities and circumstances are required to accommodate the needs of this distinct group of patients that is

The technology around mechanical circulatory support is evolving with an exponential speed which makes any prediction beyond few years futile. We can however look into current work that is focusing in the alleviation of VAD complications and is promising to become clinical practice in foreseeable future. One of these is contactless energy transfer that is combined with subcutaneous implantable batteries allowing transcutaneous energy transfer (TET) and avoid the driveline passing through the skin eliminating the 'Achilles' heel' of MCS Systems [23]. Further work involves strategies aiming for early and more sensitive recognition and treatment of certain complications especially the likes of pump thrombosis. These techniques use remote monitoring systems with in-time assessment and intervention of pump readings and parameters to more finely tune the VAD therapy [24]. Improved biocompatibility of materials used and rotor design will surely be helpful to reduce thrombosis risk as well as to reduce shear forces affecting blood components. Further miniaturisation and less invasive techniques of implantation can be expected to become more common place in the near future and will allow to expand the age spectrum of the recipients. Better understanding and management of right ventricular dysfunction may be coupled with more intuitive bi-ventricular support in order to achieve better and sustainable results. With improved results and better control of complications one can expect to broaden the spectrum of recipients to less sick patients and include Intermacs classes 5 and above to preemptively avoid end-organ dysfunction of heart

Within a relatively short period of emergence the implantation of left ventricular assist devices have made a huge impact in treatment of end-stage heart failure patients. The development of a new treatment method inevitably brings with it new challenges that limit its spectrum of utilisation. LVAD specific challenges which represent the limiting factors are mainly driveline infections, anticoagulation balances, cerebral incidents and right ventricular dysfunction. We can be optimistic that current research will lead to progress in tackling of these challenges so that we will be able to claim that this therapy method represents a first line management plan for HF patients. Notwithstanding the recent encouraging attempts of widening the donor pool to donation after circulatory death, the number of heart transplantation worldwide has reached a plateau and is only available to very few select types of patients. The prospect of much improved mechanical support methods for the circulation with better manageability represents a real hope for patients in wider age spectrum as well as in earlier phases of disease

certain to grow in numbers in the not so far future.

**4. Future developments**

242 Advances in Extra-corporeal Perfusion Therapies

failure patients.

**5. Conclusions**

The authors have no conflicts of interest to declare.
