Introduction:
Durable mechanical circulatory support (MCS) is a key therapy for advanced heart failure. In 2021, the HeartWare HVAD (HVAD)—one of the primary devices used for MCS—was globally withdrawn due to high rates of pump thrombosis and neurological adverse events. This established the HeartMate 3 (HM3) as the current standard of care.

Aim:
This review synthesizes the biomechanical differences between the HVAD and HM3. It also provides a clear overview of the clinical consensus and the surgical strategies needed for device exchange.

Material and methods:
For this narrative review, a comprehensive literature search of the PubMed/MEDLINE database was conducted to find peer-reviewed articles on the biomechanics, clinical outcomes, and surgical exchange protocols for the HVAD and HM3 systems.

Results and discussion:
The narrow-gap design of the HVAD causes higher shear stress than the fully magnetically levitated HM3. Because device exchange carries an approximate 10% 30-day mortality rate, STS-INTERMACS registry data support a conservative "for cause" exchange strategy rather than elective replacement. During emergency exchanges, surgeons face hardware incompatibility and severe mediastinal adhesions. Managing these challenges requires off-label techniques, such as removing the retained apical sewing ring or using extra-anatomic outflow graft anastomoses.

Conclusions:
Although the HM3 improves survival, losing the smaller HVAD creates a treatment gap for patients with limited chest space, affecting both adult and pediatric populations. Until new compact devices are available, clinicians must focus on strict medical management of retained devices and refine high-risk surgical exchange strategies.