Indications for long-term assist device placement as bridge to transplantation

The current indications for long-term mechanical support as bridge to transplantation first require the patient to be a transplant candidate. Often times a patient presents with limited history and refractory cardiogenic shock, where a full transplant work-up for contraindications cannot be safely performed. The use of short-term mechanical support can be used to help filter out many patients who have easily identifiable contraindications to heart transplant. Nevertheless, patients need to be listed for a heart transplant before the implantation of some of these devices. This paradigm needs to be altered, because there are many instances where mechanical support can be used to support a patient for an intervention to "make" them a transplant candidate where they otherwise would not have been. Long-term mechanical support can overcome the cardiac contraindication to the surgical/interventional therapy to "cure" them of the process that would have prevented them from being a good cardiac transplant candidate in the first place. Noncardiac surgical procedures are well tolerated in these patients [11]. The FDA is currently evaluating the Vented Electric Heartmate system for use as destination therapy for patients who are not transplant candidates. Approval for this indication (with a device that is already approved for bridge to transplantation) will allow this paradigm shift. This system could be used in the group who may be good candidates, but not determined. If they were subsequently determined to not be a good surgical candidate, they would be chronically supported with the LVAD as destination therapy.