Elective Total Joint Replacement in Patients With Left Ventricular Assist Devices: A Modern Case Series and Systematic Review.

Background: Advances in technology for left ventricular assist devices (LVADs) have improved their performance and increased their use as a destination therapy for advanced heart failure. As patients with heart failure live longer, there is a need to develop coordinated care models to offer elective musculoskeletal surgeries for these patients. Purpose: We sought to (1) determine postoperative outcomes in patients with LVADs undergoing elective total joint replacement (TJR) in the setting of multidisciplinary protocol-driven perioperative testing and care coordination and (2) perform a systematic review of the literature regarding the outcomes and complications of elective surgeries in patients with LVADs. Methods: We conducted a retrospective, single-center case series of patients with LVADs who underwent elective hip, knee, or shoulder arthroplasty between January 2020 and July 2024. Only patients with an LVAD at the time of their elective surgery were included (5 patients who underwent 6 surgeries). All patients were managed according to a standardized, multidisciplinary protocol and had a minimum of 1 year of clinical follow-up. The primary outcomes were in-hospital and postoperative complications, readmissions, and reoperations. We also performed a systematic review examining the outcomes of elective surgeries on patients with LVADs. We used the search terms "left ventricular assist device," "elective surgery," and "LVAD and arthroplasty." From the 18 studies included in the final analysis, we extracted data on study design, level of evidence, sample size, type of elective surgery, duration of follow-up, reoperations, and complications. Results: In the 5 patients with LVADs who underwent 6 TJR procedures, the most common complication was perioperative bleeding requiring transfusion. There were no reoperations over a 22-month average follow-up period. The systematic review showed higher rates of perioperative mortality, reoperation, and infection compared to our case series with more modern LVADs. Conclusion: The results of this retrospective, single-institution case series and systematic review suggest that TJR may be considered in patients with modern LVADs, provided that robust perioperative management and multidisciplinary support are in place. While anticoagulation and bleeding risk remain important considerations, improvements in device design and perioperative management have substantially mitigated these concerns. Level of Evidence: Level V: retrospective case series and systematic review of Level II to Level V studies.