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Selection of potential cardiac recipients is not a simple process. Identification of patients who are declining from end-stage cardiac disease and may be expected to die within 12 months or less and deciding which of a number of cardiac invalids are reasonable candidates for cardiac transplantation involves prognostication as well as a working knowledge of the expected benefits and survival rates in cardiac transplantation. Screening by means of the currently accepted contraindications for cardiac transplantation is somewhat more difficult in 1986 than it was 10 years ago when these contraindications were changing less rapidly. However, for optimal use of the limited supply of donor organs and maintenance of reasonable survival rates such screening is absolutely necessary. A second area of restriction that is less approachable by the physician is that of financial limitations. It would appear that the working poor and lower middle class may be deprived of the opportunity for cardiac transplantation much as they are deprived of the opportunity for optimal medical care in our society today.

The Jarvik-7 total artificial heart (TAH) has now been implanted in seven patients, with four (57%) suffering cerebral embolic events. Functional recovery in two patients was impaired by subsequent intracranial hemorrhage from anticoagulant therapy. The findings of a Jarvik-7 TAH explanted following a cerebral embolus are reported here. Thrombotic deposition was seen in the inner crevice formed between the two components of the aortic quick connector. In addition, deposition was seen around all four valves in the crevice formed between the valve ring and the plastic valve housing. On the atrioventricular valves, the deposition in this crevice was most severe on the outflow surface adjacent to the minor flow orifice. On the pulmonic valve, deposition was seen around the entire circumference of both the inflow and the outflow crevices. No thrombi were seen on the diaphragm, the diaphragm-housing junction, or the housing of the left ventricle. Hypercoagulability of the patient's blood gradually developed during implant, reaching a maximum on the evening before the clinical embolus. Increasing resistance to heparin was also demonstrated by in vitro testing.

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