When I entered the patient’s room, the first thing that struck me was the sight of him shackled to the bed, flanked by two officers. Since he was admitted overnight for cardiogenic shock, I couldn’t help but wonder whether the restraints were truly necessary — he was in no condition to make it out the door. The patient was transferred to our tertiary care center for evaluation of mechanical circulatory support (MCS) and potential heart transplant; his case was complex from the start.
My institution serves as a referral center for patients with advanced heart failure who require specialized therapies, including heart transplants and left ventricular assist devices (LVADs). A multidisciplinary team conducts a thorough evaluation, carefully assessing eligibility and contraindications to determine whether a heart transplant or LVAD is the most appropriate option. This process includes diagnostic tests, hemodynamic and functional assessments, and extensive risk stratification. A critical component of the evaluation is the psychosocial assessment, which examines mental health, social support systems, and substance use history to ensure candidates are suited for treatment and have the best chance for a positive outcome.
For this patient, the initial evaluation ruled against both heart transplant and LVAD. His history of substance use and his current incarceration posed significant barriers to eligibility. His hospital stay was prolonged and marked by complications, including the emergent placement of an Impella 5.5 for stabilization, distributive shock due to MRSE bacteremia, and hospital-acquired pneumonia. Eventually, he was discharged back to his correctional facility on palliative milrinone therapy, with plans for re-evaluation for advanced therapies upon his release in two months. We remained hopeful that, upon his release, he could demonstrate his commitment to sobriety and potentially qualify for advanced treatments.
Two months later, he returned with worsening heart failure symptoms. We learned that his facility had rescinded his early release due to the extended length of his hospitalization. Despite initial management with diuretics, afterload reduction, and inotrope therapy, his shock persisted, and his prognosis remained uncertain.
Despite the significant burden of cardiovascular disease among incarcerated individuals, there is limited understanding of the unique challenges in managing heart failure within the prison system. For individuals with advanced heart failure, MCS like LVADs are increasingly used as a bridge to heart transplant or as long-term therapy for those ineligible for a transplant. However, for incarcerated individuals, the application of LVAD therapy is complicated by systemic health care barriers. Incarceration should not be viewed as an absolute contraindication to LVAD therapy, highlighting the pressing need for equitable access to life-saving treatments.
In addition to the structural barriers faced by incarcerated individuals, race plays a significant role in health care access and outcomes. African American individuals are disproportionately affected by cardiovascular disease, and this inequity extends into the incarcerated population. Studies have shown that racial and ethnic minorities are less likely to receive advanced heart failure therapies, including heart transplants and LVADs, even when medically eligible. This disparity is compounded by social determinants of health, including systemic racism, which can impact the quality of care that patients receive both inside and outside the prison system. The patient in question, a Black man, faces not only the usual challenges of incarceration but also the added burden of racial health disparities that may influence his access to advanced therapies like LVADs.
Under the Eighth Amendment as well as Estelle vs. Gamble, there is a legal and ethical obligation to provide incarcerated individuals with adequate medical care. Despite international guidelines emphasizing equitable access to advanced heart failure therapies including transplant, practical implementation within the correctional system remains limited. Several factors contribute to this, including logistical challenges related to accessing specialized medical centers, continuous monitoring, and follow-up visits, which can be difficult to coordinate within the prison system. The physical limitations of prison facilities further complicate LVAD management, especially in terms of maintaining proper device hygiene, managing batteries, and providing emergency care in the event of device malfunction. Additionally, the psychological stress of incarceration, compounded by limited access to support networks, can negatively affect patient morale and compliance with treatment protocols. Security concerns and the heightened risk of infection in the high-risk correctional environment also increase complications.
While these barriers may seem prohibitive, they only underscore the necessity for correctional health care systems to adapt to the unique needs of these vulnerable patients. There is a lack of comprehensive studies that address the specific challenges faced by incarcerated individuals — such as access to health care, device management, and the overall well-being of heart failure patients. There is also a need to better understand how the correctional environment affects the long-term outcomes of LVAD recipients, particularly regarding complications like infections, device malfunctions, and psychological distress. By understanding these challenges and improving the coordination of care between correctional facilities and specialized medical centers, physicians and policymakers can develop more effective strategies to support incarcerated patients with LVADs, ultimately improving both their quality of life and medical outcomes.
For my patient, another evaluation for advanced therapies was conducted in light of his refractory cardiogenic shock. He remained ineligible for a heart transplant but was approved for an LVAD after being stabilized with aggressive afterload reduction and dual inotrope therapy.
The use of MCS in incarcerated patients with heart failure presents both opportunities and challenges. Early referral to an advanced heart failure center is critical, as it allows for timely evaluation and improved outcomes for patients with advanced heart failure. While MCS offers the potential to substantially improve health outcomes and quality of life for these patients, the numerous barriers must be addressed. Effective collaboration, communication, and coordination between correctional facilities, health care systems, and specialized medical teams are essential to providing optimal care for incarcerated patients with advanced heart failure.
What is your experience with treating incarcerated patients? Share in the comments.
Dr. Siya Bhagat is a second-year internal medicine resident and aspiring cardiology fellow. She enjoys playing pickleball, exploring new restaurants, and spending time with friends and family. She is a 2024–2025 Doximity Op-Med Fellow.
Image by Jolygon / Getty
