Abstract 4366012: Advanced Heart Failure and Mechanical Circulatory Support in the Context of Incarceration: A Clinical Challenge

Abstract

Introduction: Advanced heart failure in incarcerated individuals presents unique clinical, ethical, and logistical challenges. Mechanical circulatory support (MCS), including left ventricular assist devices (LVAD), offers life-saving therapy for patients ineligible for heart transplant. However, access remains limited in the prison system due to systemic healthcare disparities. This case highlights the complexity of managing cardiogenic shock in incarcerated patients and barriers to equitable advanced heart failure care with MCS. Case Presentation: A 57-year-old incarcerated male with non-ischemic cardiomyopathy presented with abdominal pain, dyspnea, and atrial fibrillation with rapid ventricular response. Exam revealed hypotension, cold extremities, and elevated jugular venous pressure. Workup showed a renal infarct (presumed cardioembolic), EF 8%, biventricular dysfunction, and cardiogenic shock despite cardioversion and rhythm control requiring norepinephrine (0.5 mcg/kg/min), epinephrine (0.1 mcg/kg/min), and dobutamine (2.5 mcg/kg/min). Though initially ineligible for transplant or LVAD due to incarceration and prior substance use, he was temporarily stabilized with an Impella 5.5. He was transitioned to milrinone with clinical improvement and discharged to his correctional facility with plans for reassessment for advanced options following expected imminent prison release. Unfortunately, he was readmitted with recurrent cardiogenic shock and MRSE bacteremia. Following stabilization with dual inotropes and aggressive afterload reduction as well as completion of antibiotic therapy, he underwent successful LVAD placement. Discussion: This case underscores the barriers in providing durable LVAD therapy to incarcerated patients. Coordination of care is limited by the constraints of the correctional health system, including staff education, restricted access to specialized centers, and difficulty with device maintenance such as hygiene, battery care, and emergency care in case of device malfunction. Incarceration also limits social support, impacts adherence, and contributes to psychological stress. Infection risk and security concerns further complicate care. Addressing these challenges are essential to ensure that incarcerated individuals receive equitable access to advanced heart failure therapies and thus facilitate optimal outcomes.