Adult Mechanical Circulatory Support: AATS/ISHLT Guidelines on Selected Topics in Mechanical Circulatory SupportAmerican Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support
Section snippets
Preoperative evaulation and optimization
The preoperative evaluation of a patient considered for implantation of a durable LVAD begins with assessment of the criteria that define the indication for implant (eg, bridge to transplant [BTT], bridge to candidacy, or destination therapy [DT]). Patients believed to be candidates for LVAD support commonly present with significant concomitant medical conditions, many of which are direct sequelae of the heart failure syndrome.
Several assessment tools characterize the degree of illness in
Intra-aortic balloon pump support
Intra-aortic balloon pumps (IABP) provide significant hemodynamic support by increasing stroke volume during balloon deflation and systolic blood pressure during balloon inflation. In the setting of inadequate response to escalating doses of inotropic agents, an IABP may be used to augment cardiac output, although the degree of this augmentation on average is modest, approximately an additional 0.5 L/min.54 As with patients who present in shock, an IABP may also assist in LV unloading and in
Biventricular failure: etiologies
Biventricular failure (BVF) occurs when both chambers of the heart show evidence of inadequate forward flow with appropriate filling pressures, compromising adequate oxygen delivery and maintenance of normal physiologic function.76,77 The etiology for RV failure78 can be primary, electromechanical in nature, or secondary to LV and/or pulmonary etiologies. Furthermore, RV failure can be transient and respond to medical management and/or temporary mechanical support or might be irreversible or
Operative planning
During initial patient evaluation, individual anatomical, physiologic, and technical considerations should be weighed to best assess the benefit-risk ratio of LVAD therapy and determine likelihood of long-term survival. With the average duration of LVAD support increasing and long-term support with CF LVADs going beyond 5 years, surgical techniques have evolved to address potential future issues, including pump thrombosis and progression of valvular disease in addition to the standard
Management of postoperative bleeding
Perioperative bleeding, defined as receiving >4 U packed red blood cells within 7 days of surgery or requiring a reoperation, is the most common complication after LVAD implantation, with reported rates between 20% and 81%.104, 105, 106 The high incidence following LVAD implantation is a result of preoperative heart failure that contributes to nutritional deficiency, thrombocytopenia, renal insufficiency, and hepatic dysfunction; nonphysiological sheer stress imparted by CF LVADs, with
Anticoagulation management
All recipients of CF LVADs require systemic anticoagulation to reduce the risk of device thrombosis and systemic embolization. Presently, relatively few outcome studies have examined optimal anticoagulation strategies for CF LVAD recipients. The manufacturer’s instructions for use for the HeartMate II, HVAD,132 and HeartMate 3132 provide foundational recommendations regarding the use of both antiplatelet and anticoagulant therapies at the time of device implantation and for long-term use.
For
Optimizing pump speed
The goal of pump speed adjustment is to improve the abnormal hemodynamic parameters of congestive heart failure by unloading the LV and establishing forward cardiac output. Optimization of pump operation must take into account the effect of high versus low pump speed on RV function, blood pressure, and aortic valve opening. In addition, considerations in the immediate postoperative period differ from those during long-term support. Lastly, device-specific LV unloading characteristics may
Diagnosis of pump malfunction
The clinical presentation of a dysfunctional LVAD may range from subtle and asymptomatic to catastrophic with cessation of device function. Optimal device monitoring requires a systematic, multimodality approach that integrates historical features; physical examination findings; serological evaluation; cardiac imaging; and in some instances, hemodynamic assessment. Potential failure mechanisms must be accurately and expediently assessed to detect abnormalities sufficiently early to minimize the
Management of pump-related infections
Infections in LVAD patients have been categorized by an International Society for Heart and Lung Transplantation consensus conference into 3 categories: VAD-specific, VAD-related, and non–VAD-related.196 VAD-specific infections in turn can be broken down into power cord, pump pocket, and internal surfaces (pump or cannula) infections.197 The VAD-related infections refer to infections not directly involving the VAD itself but possibly occurring as a result of VAD placement. This category would
Strategies to promote myocardial recovery
Despite the wealth of functional and biologic evidence of reverse cardiac remodeling that occurs with mechanical unloading, few patients actually proceed to functional myocardial recovery, and even fewer to the point of having their LVAD explanted. Excluding patients with acute cardiogenic shock states requiring short-term mechanical support, LVAD-associated myocardial recovery is believed to occur in <2% of all patients implanted with durable devices.
Limitations
The guidelines recommendations are summarized in Table 3. Given the experiential nature of complex surgical specialties like MCS, few aspects of standard practice are supported by randomized clinical trials. Of necessity, a majority of the guidelines included in this document are Level of Evidence C. Readers should realize that the cited recommendations are a hybrid product of true evidence-based guidelines and expert consensus opinion coupled with a review of the literature. Strict application
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This article has been copublished in The Journal of Thoracic and Cardiovascular Surgery and the Journal of Heart and Lung Transplantation.