2023 ISHLT Guidelines for Mechanical Circulatory Support
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Abstract
THE 2023 International Society for Heart and Lung Transplantation (ISHLT) guidelines for mechanical circulatory support (MCS)1 supersede the 2013 guidelines published a decade ago, incorporating substantial developments in device technology and clinical outcomes data in this field. The current guidelines have expanded on the original review of preoperative, intraoperative, and postoperative management to include 9 task forces, providing comprehensive recommendations on patient selection, preoperative optimization, intraoperative and immediate postoperative management, inpatient and outpatient postoperative management, congenital heart disease, monitoring recovery, biventricular support, and center-specific outcome metrics.
Durable MCS (DMCS) include left ventricular assist devices (LVADs), biventricular assist devices (BIVADs), or total artificial heart (TAH) implantation. Regulators in the United States of America and Europe have recognized (and approved funding for) 2 major indications for DMCS device implantation, including bridge-to-heart transplantation and destination therapy in patients with refractory heart failure (HF). A subgroup of patients falls under the bridge-to-candidacy category, as it is recognized that some patients receiving an implant but not initially listed for transplantation may benefit from improved functional status and comorbidities and subsequently become transplant candidates. In addition, between 10% and 12% of patients with nonischemic cardiomyopathy may demonstrate reverse remodeling after LVAD implantation, with responder status being defined as an LV internal diameter during diastole ≤6.0 cm and an LV ejection fraction (LVEF) ≥40%. Sufficient LV recovery permitting device explantation, termed “bridge to recovery”, occurs in 1% to 3% of all LVAD recipients, of whom 40% survive free of MCS or heart transplantation at 1 year after explantation.7 The recommended descriptors for the various applications of MCS include “short-term MCS” for bridge to recovery, bridge to heart transplantation, or bridge to candidacy indications, and “long-term MCS” for destination therapy.1 The term “extracorporeal life support” encompasses all forms of venovenous and venoarterial extracorporeal membrane oxygenation (VA ECMO) for pulmonary and cardiac support, respectively. Venoarterial extracorporeal ECMO is the preferred modality for cardiogenic shock, and when this is applied during cardiopulmonary resuscitation (CPR), it is termed “extracorporeal CPR”. The term “temporary mechanical circulatory support” (T-MCS) is recommended to describe the peripheral or central VA ECMO requirement for cardiogenic shock or cardiac arrest.
Recent international guidelines have been proposed to include a universal definition and classification of HF, defined as clinical features of HF, with either elevated natriuretic peptide concentrations or objective evidence of cardiogenic, pulmonary, or systemic congestion.12 Four stages of HF (A to D) are recognized, including at-risk, pre-HF, HF, and advanced HF, respectively. In addition, HF is further classified according to LVEF as HF with reduced ejection fraction (LVEF <40%), mildly reduced ejection fraction (LVEF 41%-49%), preserved ejection fraction (LVEF >50%), or improved ejection fraction (baseline LVEF <40%, with a 10-point increase and a subsequent LVEF >40%). The Society for Cardiovascular Angiography and Interventions (SCAI) classifies cardiogenic shock according to phenotype and etiology, risk modifiers, as well as shock severity stages A to E, according to clinical features, natriuretic peptide and lactate concentrations, and systolic blood pressure or ongoing CPR.
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