Interventional Council Publishes Algorithm For MCS Decision Making
Members of ACC’s Interventional Section Leadership Council have created an algorithm to guide interventional cardiologists in clinical decision making for choosing mechanical circulatory support (MCS) devices in patients undergoing percutaneous coronary (PCI) intervention with high-risk features or cardiogenic shock, according to a statement published May 2 in JACC: Cardiovascular Interventions. The goal was to define a practical approach for the interventional cardiologist regarding when to use MCS, how to select a device type, and practical points to consider when utilizing these devices.
According to Tamara M. Atkinson, MD, et al., MCS is used primarily in three populations – high-risk PCI, cardiogenic shock, and cardiac arrest – representing a wide spectrum of disease that requires tailored treatment. Physicians must first identify patients with cardiogenic shock or high-risk features for PCI. Next, a multidisciplinary heart team approach, including interventional cardiology, cardiothoracic surgery, critical care, and advanced heart failure physicians should be initiated. The next step is to identify disease severity from a PCI and/or shock perspective to determine the most appropriate level of support.
Several technical requirements must be considered prior to choosing a device for MCS, including identifying indications, contraindications, access site and operator experience. The learning curve that exists with these devices must also be considered. The authors discuss the device types that should be considered in different settings, including intra-aortic balloon pump, venoarterial extracorporeal membrane oxygenation, Impella or TandemHeart. Post-procedure device management when transferring patients to an intensive care unit (ICU) is also an important aspect of MCS and each institution should establish appropriate training and protocols, according to the authors.
“With multiple MCS devices available, each institution must develop a strategy for the preferred MCS device for patients with adequate training of cardiac catheterization and ICU staff,” write the authors. “A critical aspect of device management involves unification of cardiac catheterization staff, coronary care intensivists and nurses, interventional cardiologists, advanced heart failure cardiologists, and cardiothoracic surgeons to create an operational strategy for each institution. This facilitates protocols that can be used and executed in a timely manner and assist in especially for troubleshooting issues or complications. Ideally, this team should also review the outcomes for all patients treated with left ventricular support devices to tabulate and evaluate complications as well as identify process improvement areas,” they add.
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