Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association

Abstract

ABSTRACT:Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients. Mechanical circulatory support (MCS) has evolved from a rarely used therapy reserved for the most critically ill hospitalized patients to an accepted longterm outpatient therapy for treating patients with advanced heart failure. This growth is attributable to improved technology, improved survival, reduced adverse event profiles, greater reliability and mechanical durability, and limited numbers of organs available for donation. With the number of patients supported by durable MCS systems increasing in the community, so too is the need for emergency care providers to receive specific guidance on how to assess and treat a patient with MCS who is unresponsive or hypotensive.No evidence-based or consensus recommendations currently exist for the evaluation and treatment of cardiovascular emergencies in patients with MCS. Because of the unique characteristics of mechanical support, these patients have physical findings that cannot be interpreted the same as for patients without MCS. For example, stable patients supported by a durable, continuous-flow ventricular assist device (VAD) often do not have a palpable pulse. Unfortunately, different and sometimes conflicting instructions are given by hospital providers and emergency medical services (EMS) directors to EMS and other healthcare personnel on core resuscitative practices such as the role of external chest compressions in such a patient who suddenly becomes or is found unresponsive. PURPOSEThe purpose of this scientific statement is to describe the common types of MCS devices that emergency healthcare providers may encounter and to present expert, consensus-based recommendations for the evaluation and resuscitation of adult and pediatric patients with MCS with suspected cardiovascular collapse or cardiac arrest. These recommendations focus initially on emergency first-response providers, whether outside or inside the hospital, with additional sections on advanced care that may be provided in the emergency department or in-hospital settings. CONSENSUS PROCESSThe need for standardized recommendations for the emergency treatment of acutely unstable patients with MCS was identified during the 2014 meeting of the American Heart Association (AHA) Science Subcommittee. A writing group was commissioned to review the current literature and to develop consensus-derived recommendations for the initial treatment of these patients. Members of the writing group were chosen for their combined expertise in MCS, cardiopulmonary resuscitation (CPR), emergenc...

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