{"id":8668,"date":"2011-06-16T12:36:14","date_gmt":"2011-06-16T16:36:14","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=8668"},"modified":"2011-07-19T17:44:05","modified_gmt":"2011-07-19T21:44:05","slug":"case-study-advanced-heart-failure-in-a-prison-inmate","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/06\/16\/case-study-advanced-heart-failure-in-a-prison-inmate\/","title":{"rendered":"Case Study: Advanced Heart Failure in a Prison Inmate"},"content":{"rendered":"<p>A 37-year-old prisoner with end-stage nonischemic cardiomyopathy was transferred from a local county hospital to a tertiary care center for\u00a0heart failure\u00a0therapy. Soon after his arrival, he developed ventricular tachycardia and cardiogenic shock. He was sent urgently to the cardiac catheterization laboratory, where he underwent placement of an intra-aortic balloon pump (IABP). Right-heart catheterization, on dobutamine and IABP therapy, revealed:<\/p>\n<ul>\n<li>right-atrial pressure, 15 mm Hg<\/li>\n<li>pulmonary-artery pressure, 50\/33 mm Hg<\/li>\n<li>pulmonary capillary wedge pressure, 28 mm Hg<\/li>\n<li>cardiac index, 1.8 L\/minute\/m<sup>2<\/sup><\/li>\n<\/ul>\n<p>Efforts to improve the patient\u2019s hemodynamics, in order to allow weaning from the IABP, were unsuccessful.<\/p>\n<p>The patient wants to avail himself of whatever treatments will keep him alive. He has been told about\u00a0the possibility of heart transplantation\u00a0or placement of a left-ventricular assist device (LVAD). The patient\u2019s social worker reports that the patient is housed in a maximum-security facility without hope for parole.<br \/>\n<strong> <\/strong><\/p>\n<p><strong>Questions:<\/strong><\/p>\n<ul>\n<li>Is this patient an appropriate candidate for an LVAD?<\/li>\n<li>Is he an appropriate candidate for heart transplantation?<\/li>\n<li>What would be the best course of action for this patient, given his complex personal circumstances?<\/li>\n<\/ul>\n<p><strong>Response:<\/strong><br \/>\n<a href=\"..\/members\/jamesfang\/\">James Fang, MD<\/a><\/p>\n<p>The comments below from my colleagues all have valid points.  Many will recall that a <a href=\"http:\/\/www.nytimes.com\/2002\/01\/31\/us\/inmate-s-transplant-prompts-questions-of-costs-and-ethics.html\">similar case<\/a> in California about a decade ago received widespread attention when the prisoner ultimately received a heart transplant.  Other than a successful transplant, I do not know if the patient did well over the ensuing years.  Keep in mind that renal transplantation has also been performed in incarcerated patients as well.<\/p>\n<p>Without more information, it is not yet clear if the patient meets the criteria for an LVAD.  The psychosocial aspects are only one consideration.  Other medical comorbidities, the nature and extent of medical\/device therapy to date, etc. still need vetting.<\/p>\n<p>Clearly, it is a complex decision as is caring for anyone with advanced heart failure.  The sophisticated nature of this field has been recently recognized by our community and the ABIM which now acknowledges the cardiovascular subspecialty of advanced heart failure and transplantation.  Hopefully, this patient was seen and reviewed by such a subspecialist and a multidisciplinary team well versed in these issues.  Most advanced heart disease centers have multidisciplinary groups that routinely review such cases.<\/p>\n<p>An LVAD strategy is increasingly being used as a \u201cbridge to a decision\u201d in the world of advanced heart failure and this patient could fall into this category.  Arguably, compliance is less likely an issue in an incarcerated situation where the patient is under constant surveillance.<\/p>\n<p>At the end of the day, it is likely that finances will drive the decision.  Many non-incarcerated patients are routinely turned down for transplant and\/or VAD because they have no ability to pay. Like this patient, they too generally want whatever treatments will keep them alive.  It may not be fair but it is a reality.<\/p>\n<p>As for other courses of action, chronic inotropic management could be used understanding its limitations.  I would also revisit other options such as CRT and hemodynamic guided therapy.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A 37-year-old prisoner with end-stage nonischemic cardiomyopathy was transferred from a local county hospital to a tertiary care center for\u00a0heart failure\u00a0therapy. Soon after his arrival, he developed ventricular tachycardia and cardiogenic shock. He was sent urgently to the cardiac catheterization laboratory, where he underwent placement of an intra-aortic balloon pump (IABP). Right-heart catheterization, on dobutamine [&hellip;]<\/p>\n","protected":false},"author":406,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14],"tags":[287],"class_list":["post-8668","post","type-post","status-publish","format-standard","hentry","category-heart-failure","tag-heart-failure-2"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/8668","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/406"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=8668"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/8668\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=8668"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=8668"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=8668"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}