Everyone deserves a second chance: The importance of second opinions for left ventricular assist device candidacy

Although left ventricular assist device (LVAD) therapy improves survival and quality of life in patients with end-stage heart failure, appropriate patient selection is complex, with many patients being turned down for implantation because of perceived medical, surgical, or social barriers. However, some patients turned down for an implant at one center will go on to be successfully implanted elsewhere.

We conducted a retrospective review of all primary LVAD implantations at our center. Primary stratification was by prior turndown status. Primary outcome was survival as assessed by the Kaplan-Meier method and Cox proportional hazards regression modeling. Secondary outcomes included length of stay and commonly encountered postoperative complications.

From 2017 to 2025, 237 patients underwent primary LVAD implantation, 28 (11.81%) of whom were turned down for implantation at another center. When stratified by turndown status, there was no difference in operative mortality (17/209, 8.13% vs 2/28, 7.14%, p = 0.86) or 5-year survival (p = 0.73). On multivariable analysis, prior LVAD turndown was not associated with 1-year survival (HR: 0.41[0.09-1.17], p = 0.23). Moreover, patients previously turned down for LVAD had similar lengths of stay and rates of bleeding, stroke, respiratory failure, renal failure, and right ventricular failure.

Patients turned down for LVAD implantation at another center prior to referral to our center had similar short-term morbidity and mortality compared to patients not previously turned down for surgery. These findings suggest that patients with end-stage heart failure who are turned down for LVAD therapy at one center should seek or be referred for a second opinion at another center.