A Destination to Nowhere? Re-evaluating Candidacy for Mechanical Circulatory Support after Initial Rejection

Introduction Left ventricular assist devices (LVADs) are well-accepted therapy for patients with advanced heart failure. There exist very few absolute contraindications to LVAD implantation. Many centers are tasked with creating criteria for inclusion and exclusion based on guidelines. This potentially leads to a wide variation in therapy delivery. We examined a single center experience with patients who were denied an LVAD elsewhere but were granted one at our program. Case series We reviewed all LVADs implanted at our center and identified 6 patients out of 45 implanted who presented for a 2nd opinion after initial denial. Table 1 describes the characteristics of the 6 patients and how all the concerns were addressed. We used Kansas City Cardiomyopathy Questionnaire and number of readmissions post-implant (Table 2) to assess outcomes. Discussion Though hard to generalize, the majority of patients were denied initially due to psycho-social barriers. More importantly, in these 6 patients, our 6- month evaluation suggested an improvement in the KCCQ score and a reduction in readmissions. Based on these 6 patients, noncompliance, lack of social support and signs of RV failure/renal dysfunction were the general reasons for rejection from the initial evaluation. However as suggested by our dataset, most of these barriers could be overcome with counseling, task-driven follow up and improvement in perfusion. Furthermore, presumed permanent renal dysfunction improved post-LVAD suggesting a reversible cardiorenal physiology. Our 6-month survival and readmission data exceeds INTERMACS benchmarks in DT implanting centers. Conclusions The selection criteria for LVAD remains a somewhat subjective and center-specific process with guiding principles that provide few absolute contra-indications. Though psycho-social barriers remain, as pumps become easier to manage and with a better side effect profile, it is plausible that historic barriers to implant should be re-evaluated on a regular basis with the intent of helping more patients with life-saving surgery. Societal guidelines and research should begin to explore the possibility of improved outcomes in higher-risk patients.