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Mechanical Circulatory Support: Generating Consensus for Emergency Procedures

Juliane Vierecke, MD
Evgenij Potapov, MD, PhD
Deutsches Herzzentrum Berlin
Berlin, Germany

Because of the shortage of donor hearts for transplantation the numbers of VAD implantations and the number of patients living at home with a VAD are growing every year. In Germany approximately 1000 patients with VADs of different kinds are living at home.

Technical complications during MCS support are rare with modern devices but they may be life-threatening. One way to increase the acceptance of MCS in the cardiologist and home physician community—our best "suppliers"—is to inform them of the true incidence of life-threatening complications and to ease their anxiety about handling them. This would, at the same time, lower the psychological threshold for referring patients, especially for destination therapy.

We plan to reach this goal by following two approaches. The first is to prevent emergency situations from happening by instructing the patient and hospital staff on all procedures and the second is education in the management of such complications when they do occur.

In 2013 the MCS Council published comprehensive MCS guidelines, which have been very well received. Earlier this year the MCS Council in conjunction with the I2C2 committee began a project to work with Emergency Medicine providers and organizations of first responders do develop a standardized approach to patients with mechanical circulatory support. Although the process is still at its earliest stages, we would welcome input from the MCS community as we consider how best to approach this multidisciplinary project and provide applicability to the international MCS audience. We would welcome any preliminary thoughts on these and other topics:

  1. Diagnosis of emergency situations
  2. First responder approaches to the management of emergency situations
  3. Training of first responder personnel
  4. Prevention of cable damage in hospital and outside
  5. Recommendation for pump re-start CPR in VAD patients

One example of our growing knowledge and resulting changes in approach concerns the question of whether to restart a stopped pump, especially if the duration of standstill is unknown.

Restarting a VAD after a prolonged time of non-operation carries a risk of thromboembolic complications. The development of thrombus inside the pump or connecting grafts depends on the patient's anticoagulatory status, duration of the pump-stop and amount of backflow.

In patients supported with pulsatile devices we recommend not restarting the pump after 3-5 minutes because of stasis behind the valves and the lack of backflow through the device. Nowadays we support the vast majority of patients with continuous-flow pumps, which do have some backflow. Three of our CF LVAD patients suffered a prolonged pump-stop at home (up to 12 hours). The pumps were restarted by the emergency services and all patients survived without neurological problems.

Also, it was not clear whether chest compression should be performed in patients with a VAD, for example if a restart is not possible or if there is cable damage.

The Sharp Memorial Hospital, San Diego, presented a poster at the ASAIO congress 2013. They reported on seven HeartMate II patients who received chest compression. There was no inflow or outflow graft damage. Chest compression in this small cohort seems to be safe and potentially beneficial.

To allow current, changing knowledge to be applied in emergency situations, a check list and an algorithm for the management of emergencies in VAD patients should be created and made available as a matter of course to VAD patients discharged home.

As a part of community education, standardized educational programs for the fire brigade, police department and emergency services should also be adopted.

This is a huge, but important, task and will be managed and coordinated by the MCS Council.

Disclosure Statement: The authors have no conflicts of interest to report.

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