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Mechanical Circulatory Support Highlights from Prague

Jeff Teuteberg, MD
MCS Council Chair

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jeffrey teutebergI have to admit to slight trepidation when I was approached with the task of writing a brief summary of mechanical circulatory support (MCS) from the 2012 meeting. With the prodigious growth of clinical experience, clinical and basic science investigations, and novel devices or novel uses of existing devices, it seemed there was enough material to fill several installments of the ISHLT Links. While the Mechanical Circulatory Support Council will provide a more comprehensive Year in Review for the June issue of the Links, as well as a summary of the successful ISHLT Academy: Core Competencies in MCS, consider the following one person's musings on the oral abstracts.

Once again, INTERMACS (IM) has provided many useful insights into the clinical application of MCS technology. Post-approval destination therapy (DT) outcomes in IM were shown to be quite similar to clinical trial results. There is also a growing focus not only on outcomes with DT, but on quality of life (QOL) and the factors that impact QOL. Interestingly, pre-implant QOL or the degree of improvement in QOL at three months and one year did not differ based on pre-implant IM profiles. Despite improvement in numerous measures of QOL, there is still little improvement in MVO2 after MCS. The impact of older age, degree of pre-implant illness, and comorbidities continue to impact not only outcomes, but post-implant length of stay. There is also growing literature characterizing of the importance of social support and the degree of caregiver burden after MCS.

With the growth of DT, the long-term management of patients on MCS increasingly has become the focus of investigations. Several abstracts assessed the incidence of aortic insufficiency (AI) as a long-term complication of MCS. While rates varied in the series presented, less AI seems to be associated with better blood pressure control and greater degrees of aortic valve opening. Gastrointestinal (GI) bleeding is another long-term management conundrum associated with the use of continuous flow devices. While both axial and centrifugal pumps were shown to result in the loss of large multimers of von Willebrand factor, the impact of the degree of pulsatility on the rates of GI bleeding remains controversial.

Device technology was featured in abstracts presenting the experience with the CircuLite Synergy system, the Impella RP (Abiomed), and the use of the HVAD (HeartWare) in a biventricular assist configuration. Right ventricular function also remains a topic of great interest to the MCS community. The varying modalities of temporary mechanical support for the right ventricle were presented and the utility of tricuspid valve intervention at the time of MCS continues to be debated. IM data demonstrated low rates of RVAD use, but sicker patients and less pulmonary arterial pulsatility were associated with the need for right ventricular support.

Lastly, the MEDAMACS screening pilot provided insight into outcomes of patients with advanced heart failure who are IM profiles 4-7 and have several high risk features, such as recurrent admissions. At 6 months the mortality in this group was 16% and the freedom from death, transplant, MCS, or inotropes was only 64%. Both the Seattle Heart Failure Model and IM profiles were able to stratify risk in this population. For these patients QOL was seen to decrease as IM profiles increased and reduced QOL was also found to have a significant association with diabetes and employment status.

Disclosure Statement: The author has no relevant financial relationships to disclose.