Use of durable left ventricular assist devices for high-risk patients: Korean experience before insurance coverage

Background: Left ventricular assist devices (LVADs) were not covered by the Korean national insurance until September 2018, and they were implanted at the patient's own or a third party's expense. However, there have been no reports on using an LVAD without insurance coverage or manufacturer support. Methods: We reviewed 23 patients who underwent durable LVAD implantation at our institution from August 2012 to September 2018. Patients with temporary LVADs using extracorporeal or paracorporeal circulation were excluded. The available devices were the HeartMate II^TM (HMII) and HeartWare^TM Ventricular Assist Device (HVAD). The primary outcome was 30-day mortality. The secondary outcomes were postoperative complications and late mortality. Results: The mean age of the patients was 68.7±9.9 years. The study sample comprised six female (26.1%) and 17 male (73.9%) patients. All patients had modifiable (bridge to candidacy) or unmodifiable absolute (destination therapy) contraindications for heart transplantation (HT). Among the patients in this study, 12 (52.2%) had ischemic cardiomyopathy and 11 (47.8%) had non-ischemic cardiomyopathy. Nine patients (39.1%) had temporary mechanical circulatory support such as extracorporeal membrane oxygenation or a temporary LVAD in place preoperatively. The average duration of LVAD support was 618.6±563.2 days (range, 59-2,285 days). There was no 30-day mortality. Four patients (17.4%) underwent HT. Six patients (26.1%) underwent re-exploration for postoperative bleeding, and one patient (4.3%) had a disabling stroke after discharge. The estimated survival rates at 12 and 24 months were 89.2% and 68.8%, respectively. Conclusions: All patients who received LVADs before insurance coverage had contraindications for HT. The overall outcomes were comparable with those reported in the international registry.