Mechanical circulatory support guidelines issued
FROM THE JOURNAL OF HEART AND LUNG TRANSPLANTATION
The International Society of Heart and Lung Transplantation issued on Jan. 10 the first comprehensive guidelines for all phases of evaluating, implanting, and managing patients who receive left ventricular assist devices or related equipment.
"Traditionally, management of patients with mechanical circulatory support [MCS] was very center specific, but because the number of treated patients has increased, and because patients now live with these devices for years, we reached a point where we needed best practices guidelines, an expert consensus on what is the best way to approach this treatment," said Dr. Salpy V. Pamboukian, a cardiologist and one of three cochairs of the guidelines-writing project.
"We hope these guidelines will serve as a springboard for further research into the long-term management of these patients," Dr. Pamboukian, medical director of the MCS device program at the University of Alabama, Birmingham, said in an interview.
"These guidelines are much more comprehensive [than anything previously published] and they represent the opinions of the physicians, surgeons, nurses, and other providers who care for these patients," said Dr. David S. Feldman, a cardiologist who is director of the heart failure, VAD (ventricular assist device), and cardiac transplantation program at the Minneapolis Heart Institute at Abbott Northwestern Hospital, and a cochair of the guidelines committee.
The writing committee admitted up front in the paper that most of the recommendations are consensus opinions with no clear evidence base. "It’s a limitation," admitted Dr. Pamboukian, "but you need a common approach to patients."
But despite an absence of evidence on which to base many recommendations, "I was pleasantly surprised that there was more consensus than controversy. There was more commonality in our approaches than differences," she added.
The guidelines, which took about 3 years to produce, came from a committee of 35 health care providers, with initial review by three independent experts followed by additional peer review and then a period of open comment from the society’s membership. The 146-page document consists of more than 250 individual recommendations presented in five sections: patient selection; risk management prior to surgery; intraoperative procedures and immediate postoperative management; in-patient management during the immediate postoperative period; and long-term outpatient management (J. Heart Lung Transplant. 2013;32:157-187).
The fourth of the five task forces addressed inpatient management of patients with MCSDs and was cochaired by Dr. Pamboukian and Dr. Stephanie A. Moore. Select recommendations may be of interest to hospitalists.
According to this task force, a multidisciplinary team led cooperatively by cardiac surgeons and cardiologists and composed of subspecialists (palliative care, psychiatry, and others as needed), MCS coordinators, and other ancillary specialties (social worker, psychologist, pharmacist, dietitian, physical therapist, occupational therapist, and rehabilitation services) is indicated for the in-hospital management of MCS patients.
For patients who develop right heart dysfunction in the non-ICU postoperative period, the task force said, inotropic support may need to be continued beyond 2 weeks if there is elevated jugular venous pressure, signs of venous congestion, decreased VAD flows (or low pulsatility in continuous flow MCSD), or end-organ dysfunction. Once euvolemic, inotropes should be weaned cautiously, with ongoing examination for recurrent signs and symptoms of RV dysfunction.
Diuretics and renal replacement therapy, such as continuous venovenous hemofiltration, should be used early and continued as needed to maintain optimal volume status.
Cardiac glycosides may be used to support RV function. For patients with persistent pulmonary hypertension who exhibit signs of RV dysfunction, pulmonary hypertension-specific therapies, such as phosphodiesterase-5 inhibitors, should be considered.
Recommendations for neurohormonal blockade and the treatment of hypertension post-MCS implant include pharmacotherapy with heart failure medications for blood pressure management.
Echocardiography is an integral part of determining the revolutions per minute of continuous-flow pumps. Common goals include adequate LV unloading while maintaining the LV septum in the midline and minimizing mitral regurgitation. Postoperatively, the revolutions per minute of continuous-flow pumps should be set low enough to allow for intermittent aortic valve opening which may reduce the risk of aortic valve fusion and the risk of late aortic valve insufficiency.
Anticoagulation and antiplatelet therapy initiated post operatively in the ICU setting should be continued with the aim of achieving device-specific recommended INR for warfarin and desired antiplatelet effects, according to the task force.
Bleeding in the early postoperative period during the index hospitalization should be urgently evaluated with lowering, discontinuation, and/or reversal of anticoagulation and antiplatelet medications.
To reduce risk for infection after MCS placement, the driveline should be stabilized immediately after the device is placed and throughout the duration of support. A dressing change protocol should be immediately initiated post operatively. Secondary antibiotic prophylaxis for prevention of endocarditis has not been studied in the MCS population but would be considered reasonable due to the risk of bacteremia in this group.
