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."
No comments:
Post a Comment