Sex Differences in LVAD Therapy: From Diagnosis to Destination

Sex disparities in left ventricular assist device (LVAD) therapy remain a significant challenge in advanced heart failure care. This review synthesizes evidence on differences in epidemiology, clinical presentation, anatomical suitability, complications, and long-term recovery to clarify why women remain underrepresented despite comparable survival with contemporary devices.

Women constitute nearly half of the heart failure population but only 20-25% of LVAD implantations. They often present later with HF phenotypes marked by microvascular dysfunction, diastolic stiffness, smaller ventricular size, and reduced right-sided reserve, increasing perceived procedural risk. Although contemporary centrifugal-flow devices have eliminated sex-based survival differences, women experience higher rates of hemorrhagic stroke, pump thrombosis, rehospitalization, and psychosocial burden. Contributing factors include device-patient mismatch, differences in clinical presentation, and disparities in referral and timing of evaluation for advanced heart failure therapies. Emerging innovations, such as miniaturized pumps, sex-specific risk models, and improved hemodynamic assessment, aim to reduce these disparities. Achieving equity will require adaptable device designs, sex-specific diagnostic thresholds, individualized perioperative management, and greater female representation in clinical research.