When heart failure affects both the left and right ventricles—a condition known as biventricular failure—standard assist devices are often insufficient. In these scenarios, surgeons must opt for either "BivAD" support (two separate assist devices for each ventricle) or a Total Artificial Heart (TAH). The TAH is fundamentally different as it involves the removal of the natural heart’s ventricles and valves, replacing them with a mechanical unit that handles both the systemic and pulmonary circulation.

The mechanical complexity of biventricular support requires precise synchronization between the two pumping chambers to prevent pulmonary congestion or systemic hypotension. Advances in "pulsatile" versus "continuous" flow technology allow for better mimicry of natural cardiac rhythms. Technical papers within the Artificial Heart Market resource detail the pneumatic and electromagnetic drivers that power these dual-chamber systems. These documents highlight the critical importance of balancing "preload" and "afterload" within the mechanical system to maintain stable blood flow.

As TAH technology evolves, there is a push toward miniaturization to allow these devices to fit into patients with smaller chest cavities, including women and adolescents. Early models were often too large for smaller patients, limiting their clinical utility. Current research is focused on developing compact, high-output pumps that maintain the same durability as their larger predecessors, ensuring that biventricular support is an option for a broader demographic of end-stage heart failure patients.