title: Insertion of a left ventricular assist device in patients without thorough transplant evaluations: a worthwhile risk?
abstract: OBJECTIVE
  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.
authors.affiliation: Departments of Surgery and Medicine, College of Physicians and Surgeons of Columbia University, New York, NY, USA.
authors.forename: Mathew
authors.initials: M
authors.lastname: Williams
authors.forename: Jennifer
authors.initials: J
authors.lastname: Casher
authors.forename: Neel
authors.initials: N
authors.lastname: Joshi
authors.forename: Todd
authors.initials: T
authors.lastname: Hankinson
authors.forename: Michelle
authors.initials: M
authors.lastname: Warren
authors.forename: Mehmet
authors.initials: M
authors.lastname: Oz
authors.forename: Yoshifumi
authors.initials: Y
authors.lastname: Naka
authors.forename: Donna
authors.initials: D
authors.lastname: Mancini
mesh_terms: D000328:Adult; D018450:Disease Progression; D004638:Emergency Treatment; D005260:Female; D006333:Heart Failure / Q000453:epidemiology / Q000601:surgery; D016027:Heart Transplantation / Q000295:instrumentation* / Q000401:mortality; D006352:Heart Ventricles / Q000473:pathology / Q000601:surgery; D006353:Heart-Assist Devices; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009518:New York; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000453:epidemiology / Q000601:surgery; D013318:Stroke Volume / Q000502:physiology; D013997:Time Factors; D016896:Treatment Outcome