2019 EACTS Expert Consensus on long-term mechanical circulatory support

Abstract

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many—sometimes contradictory—observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

Randomized trial of a left ventricular assist device as destination therapy versus guideline‐directed medical therapy in patients with advanced heart failure. Rationale and design of the SWEdish evaluation of left Ventricular Assist Device (SweVAD) trial

“…For patients enrolled to the GD‐LVAD‐DT group surgical, technical and medical treatment will be provided according to available guidelines . This is important, in particular with respect to anticoagulation and antiplatelet therapy, infection risk, gastrointestinal bleeding, blood pressure control and other essential medical features.…”

“…Patients treated with the HM3 will receive an antithrombotic regimen comprising a vitamin K antagonist, targeted to achieve an international normalized ratio of 2–3, together with aspirin (75 mg once daily). Otherwise, HM3 patients will be treated in accordance with international guidelines and recommendations …”

“…The DT approach, which may offer extended survival for patients not suitable for HTx, has been rapidly increasing in certain countries, such as the USA and Germany . Also, guidelines on how to conduct the surgical, technical and medical aspects of LVAD‐DT treatment have emerged . However, in other countries, healthcare givers have adopted a more restrictive, or even negative, attitude toward the use of this treatment option …”

The role of long-term mechanical circulatory support in patients with advanced heart failure

“…Patient selection is of utmost importance for outcome after LVAD implantation and is performed by a specialised, multidisciplinary team in LVAD-implanting centres, who take the above-mentioned indications and contraindications into consideration [9]. As mentioned previously, patients in INTERMACS profile 1 (refractory cardiogenic shock) are generally not candidates for long-term MCS directly, but require stabilisation on temporary MCS first, to see if organ function recovers.…”

A case series of patients with left ventricular assist devices and concomitant mechanical heart valves

“…2,3 Only weak (level C) guidelines currently exist recommending to leave properly functioning mechanical mitral valves in place and to replace mechanical aortic valves with bioprosthetic valves at the time of LVAD implantation. 4,5 Valve replacement, however, is a complicated procedure that can increase the length and complications of LVAD implantation. 2,6 Many observational studies investigating outcomes of leaving the mechanical valves in place at the time of LVAD implant have reported good results with no increased risk of thromboembolism, concluding this strategy to be a good option for this subgroup of LVAD recipients.…”