Task Force 4: Inpatient Management of Patients with MCSD - The ...

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4. For patients with recurrent gastrointestinal bleeding being managed below the recommended levels of anticoagulation and antiplatelet therapy for a device, the patient and device parameters should be carefully monitored. Level of Evidence: C. Class IIb: 1. Reducing the pump speed for continuous flow pumps in the setting of recurrent gastrointestinal bleeding due to arteriovenous malformations may be considered. Level of Evidence: C. Neurological Events Neurological events can present throughout the duration of MCS. Although their frequency tends to be higher in the first 30-60 days, they can occur throughout the duration of support. 76,77 Events can differ in their etiology, relation to the device, permanence, and severity, but they remain one of the most common contributors to mortality. 27,78,79 However, even a single event can result in profound and permanent functional consequences. Comparison of the rates of neurologic events in the literature must be tempered by the device(s) implanted, the definition of a neurologic event in each study, and the duration of support. Rates of stroke and transient ischemic events (TIA) are similar with the current generation of devices (Table 2). More recently, INTERMACS definitions for adverse events are becoming widely accepted by clinicians, industry, and regulatory agencies. INTERMACS definitions of neurological dysfunction are as follows: 1. Neurological event: Any new deficit, regardless of duration or focality that is determined by neurological assessment performed by a neurologist or other qualified physician with appropriate diagnostic tests. 2. TIA: Event that lasts less than 24 hours, is fully reversible, and is not accompanied by imaging proven infarction. 3. Stroke: Event that persists beyond 24 hours or lasts less than 24 hours and is accompanied by infarction on imaging. Strokes are subcategorized into hemorrhagic or embolic. 26
INTERMACS also mandates administration of the NIH stroke scale at 30 and 60 days following the event. Pre and post-operative risk factors for the development of stroke have been described in series of patients with only or primarily pulsatile devices. 80,81 In a recent, large series of 140 patients with HeartMate II and 167 patients with HeartMate XVE devices, no differences between devices were observed in the rates of neurological complication between devices. 82 On multivariate analysis a history of stroke (odds ratio [OR] 2.37) and post-operative infection (OR 2.99) were associated with the development of neurological events. Furthermore, a combination of a history of stroke, pre and post-operative sodium and albumin, and post-operative hematocrit and infection are predictive of neurologic events. The sources of embolic events are similar to that seen in the general population. The source can be intra-cardiac from the atria or ventricles that traverse the aortic valve when it opens. Vascular thrombi can arise from existing atherosclerotic disease of the aortic arch and great vessels. Routine screening for vascular disease is part of the assessment of candidacy for mechanical support, and it may help to focus the investigation of a source if an event occurs. Sources of embolism that may be specific to MCS include clot formed from stasis in the aortic root from an aortic valve that rarely opens, or if the outflow cannula is anastamosed to the descending aorta. Large clots ingested by continuous flow pumps become fragmented if they traverse impellers due to the small clearances in such devices. However, pump malfunction can cause heating or local flow disturbances, which may be a nidus for clot formation. Recent infection may alter the coagulation milieu and predispose to clot formation. 81 Ingested clots can pass through pulsatile pumps and result in systemic embolization, or they may form on the valves or within the volume displacement chambers themselves. Given the use of anticoagulation, often in conjunction with antiplatelet therapy, hemorrhagic stroke or hemorrhagic conversion of an embolic stroke is also a risk while on MCS. Untreated hypertension may also result in the development of ischemic stokes. Altered mentation due to poor cardiac output may be observed in the setting of device malfunction or pump failure. 27
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Page 3 and 4: additive benefits on mean pulmonary
Page 5 and 6: Recommendations for Neurohormonal B
Page 7 and 8: in Task Force 3. Some surgeons elec
Page 9 and 10: MCSD surgery is advised. 19 Preoper
Page 11 and 12: catheter care. 34 The same techniqu
Page 13 and 14: 3. Pre-albumin and C-reactive prote
Page 15 and 16: those patients with learning disabi
Page 17 and 18: may also be related to the type of
Page 19 and 20: appointments after discharge from M
Page 21 and 22: domains of HRQOL (e.g., depression,
Page 23 and 24: For patients who present with gastr
Page 25: amenable to endoscopic or surgical
Page 29 and 30: 6. Discontinuation or reversal of a
Page 31 and 32: Infectious Issues The classificatio
Page 33 and 34: Level of Evidence: B. 3. A possible
Page 35 and 36: Recommendations for Inpatient Treat
Page 37 and 38: could be actuated with a hand pump
Page 39 and 40: heparin, or a heparin-alternative,
Page 41 and 42: Level of Evidence: C. Class II: 1.
Page 43 and 44: 19. Holman WL, Rayburn BK, McGiffin
Page 45 and 46: 60. McGrady A, McGinnis R, Badenhop
Page 47 and 48: 98. Cadeiras M, Nagaraj H, Kirklin
Page 49 and 50: Table 1. Causes of Deviation from N
Page 51 and 52: Table 3. Determination of MCSD Infe
Page 53: B. Deep MCSD-specific Percutaneous

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