AHA Issues Mechanical Circulatory-Support Guidance for Referring Docs

Reed Miller

November 01, 2012

CHARLESTON, South Carolina — With a new guidance on device strategies and patient selection and a planned guidance on postoperative care, the American Heart Association (AHA) is trying to bring knowledge about mechanical circulatory support (MCS) beyond transplant centers and surgeons to the doctors who are primarily responsible for caring for heart-failure patients [1].

An AHA scientific statement titled "Recommendations for the use of mechanical circulatory support: Device strategies and patient selection" is now published online October 29, 2012 in Circulation. Dr Jennifer L Peura (Medical University of South Carolina, Charleston) told heartwire that the AHA developed these recommendations for "referring physicians--general cardiologists or general physicians--who may not have the [MCS] technology in their area." The authors of the recommendations hope they will lead to more heart-failure patients being referred to an MCS device-implanting center earlier in the progression of their heart failure, before they develop hyponatremia or hypotension or need to undergo frequent hospitalizations.

"If you look at the major heart-failure guidelines, the recommendations for mechanical circulatory support are very few," she said. "This is a rapidly growing technology, and there are a lot of patients who would benefit, but there are also a lot of patients who, if we get to them too late, don't get much of a benefit."

These recommendations should help referring physicians know when to refer their patients to the centers that will provide mechanical circulatory support, she said. The document will also help surgeons and other clinicians at the advanced centers better communicate and build referral relationships. "We're hoping this will be a resource to help them risk-stratify advanced heart-failure patients and identify the appropriate time to refer them for advanced therapy and, of course, to have an understanding of the contraindications and relative contraindications, so that they can have better insight into what patients would be good candidates in our hands [and the implanting centers]," she said.

The document explains both destination therapy and bridge-to-transplant therapy with ventricular-assist devices, but it is also the first guidance to explain "how to use short-term or percutaneous devices in the whole scheme of that, because [percutaneous devices] are implanted in the cath lab instead of the operating room in those circumstances, so [the guidelines] really help the referring physician [understand] how all that fits together."

All of the members of the writing committee are affiliated with centers that implant MCS devices, including include surgeons, heart-failure specialists, and MCS coordinators.

How to Care for Patients on Circulatory Support

Peura said her group is also developing a guidance for care of MCS patients after implantation of a circulatory-support device. "A lot of these patients are returning to home communities that may be hours from the implanting center. [We want to give] first responders, emergency medical services, emergency-department doctors, and the referring primary doctors guidance on how to take care of these patients."

She said the group also hopes to eventually develop recommendations on treating patients with advanced renal insufficiency. "We do see a lot of patients whose kidneys recover [with MCS], but many others may not, and if they are heart-kidney–transplant eligible, it may be reasonable to bridge them with a [ventricular-assist device], but there are many communities where outpatient dialysis is not available for that patient," she said. "We definitely need more research in that area."

Most of circulatory-support technology supports the left ventricle, but more research and guidance are needed on treating heart-failure patients with right heart failure, Peura said. "That's the Achilles' heel of left ventricular support."

Peura has no financial relationships with any device manufacturers. Disclosures for all of the authors are listed in the paper.