Mechanical circulatory support guidelines issued

Recommendations for assessment of neurocognitive deficits include routine neurocognitive assessment at 3, 6, 12, and 18 months after implant.

Recommendations for evaluation of MCS patients with a suspected infection include a complete blood count, chest radiographic imaging, and blood cultures.

At least three sets of blood cultures over 24 hours should be drawn, with at least one culture from any indwelling central venous catheters.

For those with a suspected cannula or driveline infection, obtaining a sample for Gram stain, KOH, and routine bacterial and fungal cultures is recommended.

When clinically indicated, aspirate from other potential sources, as dictated by presenting symptoms and examination.

Directed radiographic studies based on presenting symptoms and examination are recommended.

MCS patients with incessant ventricular arrhythmias require prompt admission for further management because hemodynamic compromise may occur. Patients with ongoing VT refractory to medical therapy may require catheter ablation, which should be performed by an electrophysiologist with expertise in treating patients with MCS.

When an MCS patient is undergoing a noncardiac procedure, the MCS and surgical teams need to collaborate. For nonemergency procedures, warfarin and antiplatelet therapy may be continued if the risk of bleeding associated with the procedure is low. If therapy needs to be stopped, warfarin and antiplatelet therapy should be held for an appropriate period of time as determined by the type of procedure being undertaken and risk of bleeding. Bridging with heparin or a heparin alternative while a patient is off warfarin may be considered.

For emergency procedures, warfarin may need to be rapidly reversed with fresh frozen plasma or prothrombin protein concentrate. Vitamin K can be administered with caution, but has slower onset of action. Post procedure, warfarin and antiplatelet therapy may be resumed when risk of surgical bleeding is deemed acceptable. Patients may be bridged with heparin or a heparin alternative while waiting for the INR to reach the target range.

Dr. Pamboukian and Dr. Feldman agreed that the newly released guidelines will likely be in place for only a couple of years before a revision comes out, testament to the rapid changes in this field. Dr. Feldman cited new VADs from at least two manufacturers expected to enter first-in-man studies this year, and the continued snowballing of VAD implantation rates. The most recent 2012 numbers (through Sept. 30, 2012) from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) showed nearly 2,000 VADS getting implanted into U.S. patients last year, the highest annual rate ever.

"Because the field is growing, a lot of new centers want to establish programs. We want this treatment to reach as many appropriate patients as possible, but we want it to grow responsibly. These guidelines help establish the best practices, and help ensure that patients get the best care wherever they go," Dr. Pamboukian said.

Dr. Pamboukian said that she had no disclosures. Dr. Feldman said that he has received research support from Terumo.