title: A difficult decision: what should we do when malignant tumours are diagnosed in patients supported by left ventricular assist devices?
abstract: OBJECTIVE
  Left ventricular assist devices (LVADs) are used as a bridge to heart transplantation. During the preimplantation or pretransplantation screening, malignant tumours can be discovered. Owing to the lack of guidelines, the management is difficult. We describe our perioperative approach and the patients' outcomes.
  
  
  METHODS
  Between 2006 and 2014, 55 patients underwent implantation of HeartMate II LVAD. Five were diagnosed with malignant tumours: 2 renal, 2 lung and 1 breast tumours. The renal tumours were diagnosed during the preimplantation screening. An LVAD was implanted in both followed by partial nephrectomies 8 and 9 months later. The lung cancers were diagnosed after device implantation, a left pulmonary segmentectomy and a right upper sleeve lobectomy were performed. The breast cancer was diagnosed few months after support and a tumourectomy with lymphadenectomy was performed.
  
  
  RESULTS
  Tumour resection was performed successfully in all patients. Prior to surgery haemostasis, device and heart function were evaluated. During surgery, haemodynamics and anticoagulation were monitored. Reoperations were necessary to evacuate haemothorax after lobectomy and an abdominal haematoma post-nephrectomy. After discussion with oncologists, 3 patients were relisted for heart transplantation. Two were successfully transplanted 2 and 3 years after partial nephrectomy with an actual survival of 56 and 59 months after the cancer diagnosis. The follow-up revealed no cancer recurrences.
  
  
  CONCLUSIONS
  Malignant tumours during support with LVAD can be successfully resected. A multidisciplinary evaluation in these high-risk patients is mandatory. After careful evaluation, regaining the patient's heart transplant candidacy is possible.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital Charles Nicolle, Rouen, France hassibasmail@yahoo.fr.
authors.forename: Hassiba
authors.initials: H
authors.lastname: Smail
authors.affiliation: Department of Urology, Andrology and Renal Transplantation, Rouen University Hospital Charles Nicolle, Rouen, France.
authors.forename: Christian
authors.initials: C
authors.lastname: Pfister
authors.affiliation: Department of General and Thoracic Surgery, Rouen University Hospital Charles Nicolle, Rouen, France.
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Baste
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital Charles Nicolle, Rouen, France.
authors.forename: Catherine
authors.initials: C
authors.lastname: Nafeh-Bizet
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital Charles Nicolle, Rouen, France.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Gay
authors.affiliation: Unit of Vascular Haemostasis, Rouen University Hospital Charles Nicolle, Rouen, France.
authors.forename: Virginie
authors.initials: V
authors.lastname: Barbay
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital Charles Nicolle, Rouen, France.
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Bessou
authors.affiliation: Department of General and Thoracic Surgery, Rouen University Hospital Charles Nicolle, Rouen, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Peillon
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital Charles Nicolle, Rouen, France Department of Urology, Andrology and Renal Transplantation, Rouen University Hospital Charles Nicolle, Rouen, France Department of General and Thoracic Surgery, Rouen University Hospital Charles Nicolle, Rouen, France Unit of Vascular Haemostasis, Rouen University Hospital Charles Nicolle, Rouen, France INSERM U1096, Rouen University Hospital, Rouen, France.
authors.forename: Pierre-Yves
authors.initials: PY
authors.lastname: Litzler
mesh_terms: D000328:Adult; D019072:Antibiotic Prophylaxis; D001943:Breast Neoplasms / Q000150:complications / Q000601:surgery; D004452:Echocardiography; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000628:therapy; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000601:surgery; D008175:Lung Neoplasms / Q000150:complications / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications*; D011182:Postoperative Care; D011300:Preoperative Care
keywords: Extracardiac surgery; Left ventricular assist device; Malignant tumours; Transplantation