Pragmatic Approach to Weaning Temporary Mechanical Circulatory Support

Randhawa VK, Al-Fares A, Tong MZ, et al.
A Pragmatic Approach to Weaning Temporary Mechanical Circulatory Support: A State-of-the-Art Review. JACC Heart Fail 2021;9:664-673.

The following are key points to remember from this state-of-the-art-review describing a pragmatic approach to weaning temporary mechanical circulatory support (TMCS):

  1. Selection of TMCS devices should be tailored to the type of cardiopulmonary failure, clinical indication, predicted duration of therapy, and potential risks.
  2. Many protocols for weaning the various TMCS devices exist with limited data on best practices, which is likely due to the many configurations, sizes, and indications for use. General strategies are available for weaning, and daily assessment for readiness-to-wean from TMCS devices should be performed.
  3. TMCS weaning trials should be a controlled decrease in the level of support to assess the native heart’s ability to maintain adequate circulatory support. When stability on minimal TMCS device support is demonstrated, the patient may be ready to have the device explanted.
  4. Continued dependance of TMCS after addressing potential reversible factors should prompt consideration for advanced heart failure therapies (cardiac transplantation, durable mechanical circulatory support, palliative care).
  5. Readiness-to-wean, weaning success, and readiness-for-explant can be assessed by several factors:
    • Clinical—adequate oxygenation and ventilation, less than moderate use of vasoactive agents.
    • Hemodynamic—aortic and pulmonary artery pulsatility, mean arterial pressure ≥65 mm Hg, heart rate <100 bpm, cardiac index ≥2.2 L/min/m2, central venous pressure ≤12 mm Hg, pulmonary capillary wedge pressure ≤18 mm Hg.
    • Metabolic—lactate <2 mmol/L, improved markers of end-organ function (liver function tests, international normalized ratio, creatinine, blood urea nitrogen).
    • Imaging—left ventricular ejection fraction (LVEF) ≥25%, improved valvular regurgitation.
  6. Intra-aortic balloon pump: Three main weaning strategies include:
    • Ratio wean (most common)—reduce support from 1:1 to 1:2 to at least 1:3.
    • Abrupt stop wean—change the pump from full support to standby mode.
    • Volume wean—reduce balloon inflation volume by 10% at a time to a goal of <50%.
  7. Impella (LV support): Two main strategies include:
    • Reduce P level support by 1-2 at a time to a goal of P4 or P2 (most common).
    • Reduce from full support to half support to P2, or from full support directly to P2.
  8. TandemHeart (LV support):
    • Reduce flow by 0.5 L/min at a time to a goal of 2 L/min.
  9. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO):
    • Reduce flow by 0.5 L/min at a time to a goal of 2 L/min.
    • When ready for explant, consider use of a ventricular-specific unloading device.
  10. Right ventricular TMCS devices:
    • Impella RP—reduce P level support by 1-2 at a time to a goal of at least P3.
    • Protek Duo—reduce flow by 0.5 L/min at a time to a goal of 2 L/min.
    • TandemHeart—reduce flow by 0.5 L/min at a time to a goal of 2 L/min.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support, Interventions and Imaging

Keywords: Cardiac Surgical Procedures, Diagnostic Imaging, Extracorporeal Membrane Oxygenation, Heart Failure, Heart Transplantation, Hemodynamics, Intra-Aortic Balloon Pumping, Palliative Care, Vasodilator Agents, Ventilation, Ventilator Weaning, Weaning

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