Pre-implantation Preparation Research Articles

Complex method of preparation for <i>in vitro</i> fertilization of patients with intrauterine synechia

BACKGROUND: Intrauterine synechiae (Ascherman syndrome) is one of the fairly common causes of infertility. Despite a large number of clinical studies, there are still no effective methods of both prevention and treatment, which is one of the main causes of reproductive failures. The article discusses the experience of combined preimplantation preparation of patients with uterine factor infertility caused by intrauterine synechia. An assessment of the effectiveness of preparation for the in vitro fertilization procedure, with subendometrial use of platelet-rich autoplasma against the background of surgical, antibacterial and hormone therapy, is given.
 AIM: Evaluation of the effectiveness of complex preimplantation preparation of patients with uterine factor infertility caused by intrauterine synechia.
 MATERIALS AND METHODS: Study of the results of preparation for in vitro fertilization with thawed embryos of 30 women with infertility against the background of Asherman’s syndrome. Treatment: surgical (hysteroscopic adhesiolysis), antibiotic therapy (semisynthetic penicillin’s with clavulanic acid), hormonal support (conjugated estradiol valerate and micronized progesterone) and subendometrial administration of platelet-rich autoplasma. The main criterion for the effectiveness of treatment is the onset of biochemical and clinical pregnancy.
 RESULTS: The method of combined preimplantation preparation of infertile patients with intrauterine synechia showed high efficiency of the in vitro fertilization procedure: the onset of clinical pregnancy in 46.7% of women, live birth in 36.7%.
 CONCLUSIONS: A comprehensive method of preparation for in vitro fertilization of patients with intrauterine synechiae significantly increases the chances of successful embryo implantation during this procedure.

Methods of alveolar ridge augmentation with autograft in pre-implant preparation

Pre-implant ridge preparation using various bone augmentation methods is used to allow the insertion of endosseous dental implants in alveolar ridge atrophy. Purpose: Comparative analysis of methods to increase the alveolar bone ridges in pronounced atrophy in pre-implant preparation with autogenous bone grafts, improving and evaluation of the optimal method. Material and methods: 63 patients (20 males and 43 females) with partial edentulousness aged between 17 and 65 years, mean age 38.9 years, between 2011—2023, whose edentulous alveolar ridge corresponds to Misch’s type C-h atrophy, were studied. Three techniques were used to increase bone volume with the use of autogenous grafts: with the use of bone blocks; bone laminates according to F. Khoury; the method proposed by the authors. Results and discussion: the surgical techniques of using each method were described, the comparative analysis of the results demonstrated the effectiveness of the method proposed by the authors.

Lateral sinus floor elevation with simultaneous mucosal cysts management

Introduction. Specialists in the field often face uncertainty in deciding whether to perform sinus lifting surgery in the presence of a mucosal cyst during the pre-implantation preparation of patients with maxillary sinus pathology. While some specialists believe that the sinus lifting operation cannot be performed in the presence of sinus pathology and should be resorted to after a long period of healing, others believe that it can be performed in the presence of sinus pathology or simultaneously with sinus sanitation. As a result, there are more controversies about the treatment tactics, stages, and timing required to achieve the rehabilitation of these patients, demonstrating the significance of the problem at hand. Materials and methods. The study included twenty patients who were referred to the Department of OMF Surgery and Oral Implantology “Arsenie Guţan” and the dental clinic “OmniDent” between 20.06.2016 and 01.01.2019 for implant-prosthetic rehabilitation due to partial edentulism in the upper jaw in the lateral area and the presence of a mucosal cyst in the maxillary sinus. The first group comprised of seven patients in whom the mucosal cyst was completely removed while simultaneously undergoing lateral sinus lifting. The second group consisted of five patients, aged between 18 and 67 years (average 45 years), who underwent marsupialization of the mucosal cyst. The third group comprised of six patients in whom the cyst content was only aspirated, without removal or marsupialization of the cyst. Results. All three methods were found to be effective, although total perforations of the sinus mucosa were recorded in the first two groups, preventing the performance of sinus lifting at that stage. The method of aspirating the cystic content, however, is a simple and low-risk procedure that does not carry the risk of perforating the sinus membrane and provides predictable results. Conclusions. The mucosal cyst does not present a contraindication to sinus lifting but requires additional surgical procedures.

HISTOLOGICAL EVALUATION OF SUBCHONDRAL BONE DRILLING FOR PREIMPLANTATION PREPARATION OF OSTEOCHONDRAL ALLOGRAFTS

Despite the growing success of OCA transplantation in treating large articular cartilage lesions in multiple joints, revisions and failures still occur. While preimplantation subchondral drilling is intended to directly decrease allograft bioburden and has been associated with significant improvements in outcomes after OCA transplantation, the effects of size, number, and spacing of subchondral bone drill sites have not been fully evaluated. This study aimed to investigate the effects of drill size with or without pulse-lavage of OCA subchondral bone by quantifying remnant marrow elements using histomorphometry.With IRB and ACUC approvals, human and canine OCAs were acquired for research purposes. Portions of human tibial plateau OCAs acquired from AATB-certified tissue banks that would otherwise be discarded were recovered and sectioned into lateral and medial hemiplateaus (n=2 each) with a thickness of 7 mm. Canine femoral condyles and tibial plateaus were split into lateral and medial components with a thickness of 7 mm (n=8). Using our clinical preimplantation preparation protocol, holes were drilled into the subchondral bone of each condyle and hemiplateau OCA using either 1.6 mm OD or 3.2 mm OD drill bits from the cut surface to the cortical subchondral bone plate. One femoral condyle and one hemiplateau per drill bit size were pulse-lavaged while the corresponding OCAs were not. The mean total %-fill remaining marrow elements for each treatment group was calculated.Little to no quantifiable bone marrow element retention was noted to remain within the subchondral bone of human or canine OCA specimens after subchondral drilling of allograft bone with either drill bit size evaluated and with or without pulse-lavage. The %-fill was consistent across zones, ranging from 1-5%.This project was designed to provide a preliminary histologic evaluation of the effects of drill size on OCA preimplantation preparation efficacy based on amount of remaining bone marrow elements in human and canine femoral condyle and tibial plateau specimens. Based on these initial findings, choice of drill bit size for OCA subchondral drilling may need to be based on the associated biomechanical effects rather than effects on donor bone marrow element removal.

THE INFLUENCE OF GENERAL DISEASES ON THE RESULTS OF ALVEOLAR CREST RECONSTRUCTION. LITERARY REVIEW

Objectives. In this article we aimed to analyze the general diseases that can influence the results of the reconstruction of the alveolar ridge in preimplantation preparation. Material and methods. The study included 45 articles: 5 of them were of systematic review type, 7 of meta-analysis type, 13 clinical trials, 11 randomized clinical trials and 9 of review type. These articles were selected from the PubMed and IBN platform. Results. According to the selected keywords, the following information was obtained: the impact of the diseases on the results of the growth of the alveolar ridge was found in 93% of the studies, each presenting a rate between 10-15% of the influence. Of these, 16 publications reported about the influence of cardiovascular pathologies, 8 publications – about the impact of diabetes on alveolar ridge reconstruction, 8 articles – about the influence of osteoporosis and bisphosphonate treatment, 5 articles presented data about the influence of long-term administration of corticosteroids on ridge reconstruction and 8 articles – about other pathologies and general conditions. Conclusions. The analysis of studies about the influence of general diseases in alveolar ridge bone reconstructions highlighted the multitude of variables and parameters that can have an impact on healing in alveolar ridge reconstruction operations. The in-depth study of the patient's field, the interdisciplinary communication, the management of the associated pathology, as well as the patient's compliance can lead to the decrease of the risks associated with these types of interventions.

Uterus transplantation: state of the art in 2021.

To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. Literature review and expert commentary. Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.

How preconditioning and pretensioning of grafts used in ACLigaments surgical reconstruction are influenced by their mechanical time-dependent characteristics: Can we optimize their initial loading state?

PurposeConsensus about a pre-implant preparation protocol adaptable to any graft used in Anterior Cruciate Ligament reconstruction is still lacking. In fact, there is not agreement on reliable metrics that consider both specific graft dimensional characteristics, such as its diameter, and the inherent properties of its constitutive material, i.e. ligaments or tendons. Aim of the present study was to investigate and propose the applied engineering stress as a possible metrics. MethodsPreconditioning and pretensioning protocol involved groups of grafts with different section (10 or 32 mm2) and materials (i.e. human patellar and hamstring tendons, and synthetic grafts). A 140 N load was applied to the grafts and maintained for 100 s. Initial stress and following stress-relaxation (a mechanical characteristic that can be related to knee laxity) were specifically analysed. FindingsInitial stress, ranging between 4 and 12 MPa, was affected primarily by the graft cross-section area and secondarily by the choice of the graft material. In terms of loss of the initial stress, stress-relaxation behaviour varied instead on a narrower range, namely 13–17%. InterpretationEngineering stress can be identified as the correct metrics to optimize the initial state of each graft to avoid excessive stiffness, laxity or fatigue rupture phenomena.

Можливості застосування латеральных (дискових) імплантатів у випадках атрофії дистальних відділів нижньої щелепи: результати власного клінічного досвіду

Summary. Distal mandibular aspects, especially in conditions of atrophy of the alveolar processes, are traditionally considered unfavorable for dental implantation, which is primarily due to unsatisfactory anatomical and topographic peculiarities (proximity of the inferior alveolar nerve, presence of the mandibular fossa) and require on the pre-implant preparation stage a row of additional surgical procedures aimed on increasing of bone volume or an employment of alternative implantation techniques. Aim – summarizing of own experience of placement of lateral (disc) implants in cases of severe distal mandibular atrophy. Materials and methods. 10 patients (men – 3, women– 7) with uni-, bilateral free-end defects or total mandibular adentia were examined and treated. 22 lateral (disc) implants BOI® (Ihde Dental AG, Switzerland) were installed in combination with 1-stage screwable compression implants KOS®, TPG® Uno (Ihde Dental AG, Switzerland) and loaded immediately within 3–4 days. Results. On the control clinical and roengenological inspections 6-9 mo post-op 20 (90.9 %) of 22 installed lateral (disc) were stable, painless at percussion, with absence of evident inflammation around them, demonstrating the signs of osteointegration. There was no one case of complications due to direct mechanical damage of mandibular canal walls by disc components of the implants. Conclusions. Placement of lateral (disc) implants in distal mandibular aspects creates a serious alternative to generally recognized techniques of pre-implant surgery, allows to provide a functional status of dento-maxillary system in shortest terms owing to realization of their immediate loading protocol. Key words: distal mandibular aspects, atrophy of the alveolar process, pre-prosthetic preparation, lateral (disc) implantation.

ENDOMETRIC FACTOR OF ENDOMETRIOSIS-ASSOCIATED INFERTILITY

BACKGROUND Despite numerous studies and a not decreasing amount of endometriosis and associated infertility, the study of endometriosis- associated infertility does not lose its relevance, and the characteristics of the endometrium is appeared to be central and predictive factors that determine the success of overcoming infertility. OBJECTIVE To reflect the molecular genetic features of the state of the endometrium with endometriosis associated with infertility, expand the understanding of its pathogenesis, substantiate theoretical aspects of the use of hormonal preimplantation preparation of the endometrium in endometriosis-associated infertility. MATERIALS AND METHODS To write this review, we searched for domestic and foreign publications in Russian and international search systems (eLIBRARY, PubMed, MedLine, Crossref, etc.) over the past 1–16 years. RESULTS The model of changes in endometrial receptivity is examined the mechanisms of resistance to progesterone and overproduction of estrogens as key endometrial factors in the pathogenesis of endometriosis-associated infertility and theoretical justification for the use of hormonal therapy for the preimplantation preparation of compromised endometrium is given. CONCLUSION Despite the large number of publications, there is no consensus and the same approaches to determining the receptivity of the endometrium and its role in implantation disorders in endometriosis, as well as clear ideas about the pathogenesis of endometriosis-associated infertility. A personalized approach in the management of patients with endometriosis-associated infertility will lead to a common denominator of many factors affecting reproduction and determine their potential role in both the diagnosis and treatment of a particular patient.

Infertility against the background of chronic endometritis and vaginal dysbiosis: preimplantation preparation experience

Introduction. Vaginal infections of nonspecific etiology caused by microbiocenosis disorder is one of the leading aspects of gynecological morbidity in recent times. According to research statistics, the incidence of such disease varies from 30 to 80% among all inflammatory lower genital tract diseases in women. Aim of the study: to present the experience of preparation for ART in patients with chronic endometritis against the background of mixed forms of vaginal dysbiosis. Material and methods. The results of treatment with a drug containing metronidazole and miconazole nitrate (vaginal suppositories once a day at bedtime for 7 days) were studied in combination with natural micronized progesterone in 36 women with infertility caused by endometrial receptivity disorder due to chronic endometritis against the background of vaginal dysbiosis, in whom pre-implantation preparation with embryo transfer was carried out after the end of the therapy. The following were used: assessment of microbiota status of urogenital tract – PCR (femoflor-16), measurement of vaginal environment pH, Hay/Ison criteria, endometrial pipelle biopsy and endometrial immunohistochemical evaluation of endometrial receptivity (LIF, LIF-R) on the 3rd and 7th days after LH peak. Conclusion. The presented experience of complex local therapy of women diagnosed with “Infertility against the background of chronic endometritis and vaginal dysbiosis“ using a drug containing metronidazole and miconazole and natural micronized progesterone in the form of vaginal gel can be useful for practicing obstetricians-gynecologists and other interested specialists.

MECHANISMS UNDERLYING BIOPROSTHETIC HEART VALVE DYSFUNCTIONS

The article presents new insights into the mechanisms underlying bioprosthetic heart valve dysfunctions based on the medical literature analysis. We highlighted the main pathogenetic mechanisms causing dysfunctions of bioprosthetic heart valves among the well-known and recently studied ones. In addition to the process of natural “aging” of the valve tissue that develops during continuous cyclic mechanical loads and is accompanied by the formation of calcification foci (passive and active calcification process), the negative impact of prosthesis- and recipientrelated factors has been evaluated. The prosthesis-related factors contributing to the development of dysfunctions include technological and technical factors, which may produce negative effects on bioprosthetic heart valves during the preimplantation preparation and implantation itself. Main dysmetabolic, immune, hemostasis and hyperproliferative (hyperplastic) mechanisms have been reviewed from the standpoint of the recipient-related factors that may shorten the lifespan of bioprostheses. Therefore, we propose a classification of bioprosthetic heart valve dysfunctions based on the underlying pathogenetic mechanisms and specific morphological patterns.

Distraction osteogenesis on microvascular bone flaps: histological analysis

Despite the high osteoinductive potential of vascularized autograft, being used to close significant jaw defects, the processes of osteoresorpton during remodeling in the oral cavity also affect them. The possibilities of distraction osteogenesis allow to restore the necessary volume of bone's tissue at one stage with minimal traumaticity and predictable result, however it's use on vascularized autografts causes a lot of controversy regarding its effectiveness. There has been held a clinical-experimental study of 60 people with jaw defects with various etiologic factors, which were divided into 2 groups: 1 group with defects without previously made osseous plastic, 2 group with defects partially restored by microvascular autografts. Both groups of patients underwent the method of distraction osteogenesis as pre-implantation preparation. At the stage of dental implantation, histological biopsies were taken from the area of the obtained regenerate, to study and visualize the processes during distraction osteogenesis of micro-vascular autografts. There have been received convincing results about the consistency of the distraction regenerate of both groups and have been revealed the high regenerative potential of microvascular autografts.

Adenosine triphosphate as a molecular mediator of the vascular response to injury

BackgroundHuman saphenous veins used for arterial bypass undergo stretch injury at the time of harvest and preimplant preparation. Vascular injury promotes intimal hyperplasia, the leading cause of graft failure, but the molecular events leading to this response are largely unknown. This study investigated adenosine triphosphate (ATP) as a potential molecular mediator in the vascular response to stretch injury, and the downstream effects of the purinergic receptor, P2X7R, and p38 MAPK activation. Materials and methodsA subfailure stretch rat aorta model was used to determine the effect of stretch injury on release of ATP and vasomotor responses. Stretch-injured tissues were treated with apyrase, the P2X7R antagonist, A438079, or the p38 MAPK inhibitor, SB203580, and subsequent contractile forces were measured using a muscle bath. An exogenous ATP (eATP) injury model was developed and the experiment repeated. Change in p38 MAPK phosphorylation after stretch and eATP tissue injury was determined using Western blotting. Noninjured tissue was incubated in the p38 MAPK activator, anisomycin, and subsequent contractile function and p38 MAPK phosphorylation were analyzed. ResultsStretch injury was associated with release of ATP. Contractile function was decreased in tissue subjected to subfailure stretch, eATP, and anisomycin. Contractile function was restored by apyrase, P2X7R antagonism, and p38-MAPK inhibition. Stretch, eATP, and anisomycin-injured tissue demonstrated increased phosphorylation of p38 MAPK. ConclusionsTaken together, these data suggest that the vascular response to stretch injury is associated with release of ATP and activation of the P2X7R/P38 MAPK pathway, resulting in contractile dysfunction. Modulation of this pathway in vein grafts after harvest and before implantation may reduce the vascular response to injury.

Life Cycle Assessment Interpretation and Improvement of the Sicilian Artichokes Production

This paper presents the results obtained from the Life Cycle Assessment (LCA) of the production of Sicilian artichokes (Cynara scolymus) with the aim of reducing impacts, interpreting the results, suggesting possible improvements and enriching the sustainability knowledge already existing in the agro food field. Artichokes represent one of the excellent Italian agricultural products even if still not well-known and not appreciated despite their nutritional and functional quality. According to FAOSTAT (2013) data, Italy is the world leader in artichokes production, grown mainly in the central and southern regions of Italy, in particular in Sicily, Apulia and Sardinia. In particular, among all the Italian regions, Sicily, which is highly suited for this type of cultivation, is ranked first in terms of quantity produced: the reason for this lies in the excellent combination of climate and geological conformation of the soils. The study was conducted in accordance with the ISO standards 14040 and 14044 (2006), with the functional unit of 1 ha of land and, as the system boundaries being the phases of: pre-implantation preparation of the field; artichoke implantation; and harvesting. The most impacting phases are those related with the consumption of fuel and fertilizers as well as with the use of the PVC pipes for irrigation. Possible improvements could be the use of methanol instead of the naphtha (reduction of the total damage of about 13%) and the possibility of recycling the PVC pipes once the field is dismantled (furthermore reduction of the damage of about 3%).

Bioprosthetic Heart Valves: Impact of Implantation on Biomaterials

Prosthetic heart valves are commonly used in the treatment of valvular heart disease. Mechanical valves are more durable than the bioprosthetic valves; however, the need for long-term anticoagulant therapy renders them unsuitable for some patient groups. In this paper we discuss the different types and models of bioprosthesis, and in particular, pericardial bioprosthesis. We also discuss the preimplantation preparation processes, as well as their postimplantation changes and modes of failure.

Application of screw-retained and cement-retained implant supported fixed restorations: A case report

Implantology has become an important therapeutic procedure that allows complete aesthetic and functional rehabilitation of the oro-facial system in edentulous patients. Implant supported prosthetic restorations can be fixed in two ways, by cement or screws. Both techniques have advantages and disadvantages and their selection depend on situation in patient?s mouth. The aim of this study was to describe complete process of prosthetic rehabilitation in an edentulous patient, from pre-implant preparation, through implant placement and fixation of final restoration on implants. In this case report, one ceramo-metal bridge was fixed by screws in the lower jaw while the other one was fixed using glass-ionomer cement in the upper jaw. After bone augmentation and time necessary for its osseointegration (6 to 8 months), 16 implants were placed in both jaws. Eight weeks after the implant placement, final prosthetic rehabilitation was achieved by cementation of one ceramo-metal bridge in the upper jaw using glass ionomer cement and fixation of the second bridge with screws in the lower jaw. To achieve successful implant supported prosthetic rehabilitation, the treatment protocol must be followed from the beginning to the end of the therapy.

Ethical Considerations for Ventricular Assist Device Support: A 10-Point Model

The potential for long-term support on a ventricular assist device (VAD) in the bridge-to-transplant (BTT) and destination therapy (DT) settings has created unprecedented ethical challenges for patients and caregivers. Concerns include the patient's adaptation to life on a device and the ethical, clinical, and practical issues associated with living on mechanical support. On the basis of our experience treating 175 consecutive VAD patients, we have developed a model to address the ethical and psychosocial needs of patients undergoing VAD implantation. Patient preparation for VAD implantation encompasses three phases: 1) initial information regarding the physical events involved in implantation, risks and benefits of current device technology, and the use of VAD as a rescue device; 2) preimplant preparation including completion of advance directives specific to BTT/DT, competency determination, and identifying a patient spokesperson, multidisciplinary consultants, and cultural preferences regarding device withdrawal; and 3) VAD-specific end-of-life issues including plans for device replacement and palliative care with hospice or device withdrawal. This three-phase 10-point model addresses the ethical and psychosocial issues that should be discussed with patients undergoing VAD support.

Cell Origin and Culture History Determine Successful Integration of Neural Precursor Transplants into the Dentate Gyrus of the Adult Rat

The success of transplants of neural tissue into the adult dentate gyrus in generating mature neurons is highly variable. Here we address the roles of the origin of the tissue and its pre-implantation preparation, and show that both are critical. We transplanted neonatal cultured or primary rat cells from either the ventral subventricular zone (vSVZ) or the dentate gyrus (DG) into the adult rat DG. Only primary DG cells robustly generated DG neurons (80% NeuN and Prox1-positive cells at 6 weeks), substantially repaired the damaged DG, and formed glutamatergic projections to the target CA3 region. Cultured DG cells expanded for 7 days showed limited neuronal differentiation after transplantation (10% NeuN and Prox1-positive cells) whereas cultured or primary vSVZ cells failed to make any Prox1-positive DG granular neurons. We found that a specific population of postmitotic young neurons (triple doublecortin/NeuN/Prox1-positive) were particularly abundant in primary DG cells, but were markedly reduced in the cultured DG cells and were absent in the cultured and primary vSVZ cells. Labelling of primary DG cells with the mitotic marker BrdU suggested that postmitotic young neurons are the source of the transplanted mature neurons in-vivo. We conclude that both the origin and pre-transplantation history of donor cells are key factors that determine the outcome of transplantation. These findings may be of therapeutic interest for cell replacement therapy in treating the damaged hippocampus.

Preimplant preparation of the extraction alveolus with the deproteinized bovine bone and calcium-sulphate

Different materials are used to prevent the resorption of alveolar bone. The aim of this report was to show the radiographical and histological results prior to implant insertion, when a deproteinized bovine bone mineral (BioOss) and calcium-sulphate were placed into the extraction socket immediatelly after the tooth removal. A 22-year-old woman was scheduled for the removal of the second lower molar when the extraction socket was filled with BioOss covered with calcium-sulphate as a resorbable membrane. Primary closure of the surgical site was performed. Radiography was done 4 and 12 months later. One year after the surgery, when the implant was inserted, a biopsy of the new regenerated bone was obtained for the histological evaluation. The lamellar bone was evident using both materials. The resorption of BioOss was slow and the connective tissue was observed. Both materials had biocompatible and oseoconductive properties. One year after the grafting procedure, we observed the lamellar bone and partial resorption of BioOss, while calcium-sulphate showed no significant effect as a resorbable membrane.

Withdrawal of Ventricular Assist Device Support

Ventricular assist devices (VAD) are mechanical pumps implanted into patients with advanced heart failure who are at risk of imminent death. VADs are a treatment and not a cure, and mortality on device support remains high. Recognizing the dire nature of the decisions for patients and families and the associated high mortality rates, we actively included processes for device withdrawal as part of our program mandate. At Toronto General Hospital, from October 2001 to December 2004, 22 patients underwent implantation of a VAD. Seven patients died following device withdrawal. The average time spent on support prior to device withdrawal was seven days. In four of the seven cases, family members initiated discussions regarding device withdrawal. Family-initiated discussions were more likely to occur if patients were implanted electively, as a bridge to transplantation. Disagreements occurred between the ICU and the transplant teams regarding the timing of device withdrawal and responsibility for stopping the pump. Establishing a process for device withdrawal has been a key factor in the success of our VAD program. This process relies heavily on pre-implantation preparation, a strategy for resolving disagreements, and a process for withdrawing device support.