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J Thorac Cardiovasc Surg 2003;126:436-441
© 2003 The American Association for Thoracic Surgery

Cardiopulmonary support and physiology

Insertion of a left ventricular assist device in patients without thorough transplant evaluations: a worthwhile risk?

^a College of Physicians and Surgeons of Columbia University, Departments of Surgery & Medicine, New York, NY, USA

Received for publication May 21, 2002; revisions received July 22, 2002; revisions received October 17, 2002; accepted for publication November 5, 2002.

^* Address for reprints: Dr Yoshifumi Naka, New York Presbyterian Hospital/Columbia-Presbyterian Center, Division of Cardiothoracic Surgery, Milstein Hospital Bldg, 7-435, 177 Ft Washington Blvd, New York, NY 10032, USA
yn33{at}columbia.edu

OBJECTIVES: Patients in acute cardiogenic shock may require placement of left ventricular assist devices before undergoing standard pretransplant evaluations. This practice raises ethical and logistic concerns and has led us to investigate the short- and long-term outcomes for this patient population.

METHODS AND RESULTS: We examined our adult bridge-to-transplant left ventricular assist device population over a 6-year period to characterize those patients with acute cardiogenic shock who received left ventricular assist devices on an emergency basis (ie, placement of a device within 24 hours of being listed for cardiac transplantation). Outcomes before and after transplant were compared with those of candidates with nonemergency evaluations by Kaplan-Meier survival curves and the Fisher exact test where appropriate. Of the 115 patients who required left ventricular assist device support, 73 (63%) patients required emergency placement; 70% of these patients survived to transplant compared with 83% of those with nonurgent device implantation (not statistically significant). Posttransplant survival curves were similar for patients with emergency device placement and those with nonurgent placement (not statistically significant). Twenty-two patients having emergency device placement did not undergo heart transplantation because of multisystem organ failure (14), device support withdrawal from irreversible neurologic injury (4), device or technical problems (2), and left ventricular assist device explant due to myocardial recovery (2).

CONCLUSIONS: At our institution, the majority of left ventricular assist devices are placed on an emergency basis. Few of these patients require discontinuation of device support due to undetected conditions during abbreviated preoperative evaluation. Survival before and after transplant is comparable with those of patients who undergo nonurgent left ventricular assist device placement or medical therapy.