Pharmacological management of major complications following left ventricular assist device implantation in type 2 diabetes mellitus

Left ventricular assist devices (LVADs) represent a cornerstone therapy for advanced heart failure. However, their efficacy in patients with type 2 diabetes mellitus (T2DM) is challenged by diabetes-exacerbated complications. To determine optimal pharmacological strategies to mitigate major LVAD-related complications in patients with T2DM. This review provides evidence for pharmacological strategies to mitigate major LVAD-related complications in T2DM, in which endothelial dysfunction (<i>via</i> impaired PI3K/Akt-NO signaling), chronic inflammation, and diabetic nephropathy amplify the risk of thrombosis, bleeding, infection, and right ventricular (RV) failure. For thromboembolism prevention, individualized warfarin management (international normalized ratio: 2.0-3.0) with intensified monitoring is essential, while aspirin omission in magnetically levitated devices (2 trials) reduces bleeding. Phosphodiesterase-5 inhibitors show promise for thrombosis reduction, but require bleeding risk assessment. Glycemic control necessitates the proactive de-escalation of insulin/sulfonylureas post-LVAD owing to improved insulin sensitivity and hypoglycemia risks, favoring SGLT-2 inhibitors/GLP-1 receptor agonists for cardiometabolic benefits. Driveline infection management requires renal-adjusted antimicrobial prophylaxis, culture-directed therapy, and novel approaches for drug-resistant cases. The prevention of RV failure depends on preoperative hemodynamic optimization and post-operative inotropic support. A multidisciplinary approach integrating anticoagulation precision, infection control, glycemic tailoring, and hemodynamic stabilization is critical to counter T2DM-pathophysiology interactions.