A Pragmatic Approach to Weaning Temporary Mechanical Circulatory Support

A State-of-the-Art Review

Varinder Kaur Randhawa, MD, PHD; Abdulrahman Al-Fares, MD; Michael Z.Y. Tong, MD, MBA; Edward G. Soltesz, MD, MPH; Jaime Hernandez-Montfort, MD, MPH; Ziad Taimeh, MD; Aaron J. Weiss, MD; Venu Menon, MD; Joseph Campbell, MD; Paul Cremer, MD, MPH; Jerry D. Estep, MD

Disclosures

JACC Heart Fail. 2021;9(9):664-673. 

In This Article

Abstract and Introduction

Abstract

Temporary mechanical circulatory support (TMCS) provides short-term support to patients with or at risk of refractory cardiogenic shock. Although indications, contraindications, and complications of TMCS may guide device selection, optimal strategies for device weaning and explant remain poorly defined. Under the revised adult heart allocation policy implemented by the United Nations for Organ Sharing in October 2018, rejustification of heart transplant listing status includes demonstrating TMCS dependency with attempted device wean trials. However, standardized device-specific weaning and explant protocols have not been proposed or evaluated. This review highlights when to use percutaneous TMCS in cardiogenic shock, with a focus on weaning and explant considerations. Terminology for important concepts that guide device escalation, de-escalation, and explantation have been defined. Clinical, hemodynamic, metabolic, and imaging features have been defined, which can guide a tailored approach to TMCS weaning and explant based on the approach used at the Cleveland Clinic. A narrative review of published studies that have reported TMCS weaning protocols and survey results of member centers from CS-MCS working group centers is also provided. Future research is needed to better understand optimal timing and implementation of standardized protocols to achieve successful TMCS weaning and explant.

Introduction

Temporary mechanical circulatory support (TMCS) provides short-term support in patients with, or at risk of, refractory cardiogenic shock to help restore adequate tissue perfusion. Cardiogenic shock can result from multiple etiologies, including acute myocardial infarction (AMI) and decompensated heart failure. In such settings, TMCS can serve as a bridge to recovery or bridge to decision toward heart transplantation, a durable continuous-flow left ventricular (LV) assist device, total artificial heart, or withdrawal of care. TMCS use has expanded to provide prophylactic circulatory support for high-risk cardiac interventions such as coronary revascularization, arrhythmia ablation, or transcatheter or surgical valve interventions.[1,2] Under the revised United Nations for Organ Sharing adult heart allocation policy implemented in October 2018, rejustification of transplant listing status includes demonstrating TMCS dependency with attempted device wean trials.[3] This review highlights when to use percutaneous TMCS in cardiogenic shock, with a focus on weaning and explant considerations. We define terminology for important concepts that guide device escalation, de-escalation, and explantation. We also discuss clinical, hemodynamic, metabolic, and imaging features that can guide device tailoring based on the approach taken at our institution, a narrative review of published studies that reported TMCS weaning protocols and survey results from cardiogenic shock–mechanical circulatory support (MCS) working group centers. For an in-depth review to optimize care for patients with TMCS, we refer readers to a recent review by Balthazar et al.[4]

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