ABC | Volume 111, Nº1, July 2018

Special Article Ayub-Ferreira Guidelines for MCS of the BSC Arq Bras Cardiol. 2018; 111(1):4-12 Chart 1 – Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles Profile Description Hemodynamic status Time frame for definitive intervention 1 Critical cardiogenic shock Persistent hypotension despite the use of inotropes and intra‑aortic balloon pumps, associated with organic dysfunction Hours 2 Progressive decline, but inotrope dependent Deterioration of renal and hepatic function, nutritional status and lactate levels, despite use of inotropes in optimized doses Days 3 Stable but inotrope dependent Clinical stability on continuous inotropic therapy, and history of failure to wean from it Weeks – months 4 Frequent hospitalization Signs of water retention, symptoms at rest and frequent admissions to emergency departments Weeks – months 5 At home, exertion intolerant Intolerant to activity, comfortable at rest despite water retention Intervention emergency depends on nutritional status and organic dysfunction severity 6 Exertion limited Moderate limitation to activity; absence of signs of hypervolemia Intervention emergency depends on nutritional status and organic dysfunction severity 7 NYHA III Hemodynamic stability and absence of hypervolemia Intervention is not indicated NYHA: New York Heart Association. Chart 2 – Risk predictors for mechanical circulatory support device implantation Risk score for destination therapy 6 Risk score for bridge/destination therapy (HMII score) 7 Pre-operative risk score 8 Pre-operative risk score 9 Risk of 90-day in-hospital mortality (pulsatile flow) Ninety-day mortality (continuous flow) Mortality risk after MCSD implantation (mean of 84 days) Mortality risk after MCSD implantation (mean of 100 days) Platelets < 148.000/µL OR: 7.7 Age (for 10 years) OR: 1.32 Urine flow < 30 mL/hour RR: 3.9 Respiratory failure /sepsis OR: 11,2 Albumin < 3.3 mg/dL OR: 5.7 Albumin OR: 0.49 CVP > 16 mmHg RR: 3.1 Right heart failure OR: 3.2 INR > 1,1 OR: 5.4 Creatinine OR: 2.1 Mechanical ventilation RR: 3 Age > 65 years OR: 3.01 Use of vasodilator OR: 5.2 INR OR: 3.11 Prothrombin time > 16 seconds RR: 2.4 Postcardiotomy acute ventricular failure OR: 1.8 Pulmonary artery medium pressure < 25 mmHg OR: 4.1 Center volume < 15 implants OR: 2.24 Reoperation RR: 1.8 Acute myocardial infarction OR: 1.7 ALT > 45 U/mL OR: 2.6 Leucocytes > 15.000 RR: 1.1 Hematocrit < 34% OR: 3,0 Temperature > 101.5 F RR: 0 BUN > 51 U/dL OR: 2.9 Intravenous inotropic support OR: 2.9 HMII: HeartmateII; OR: odds ratio; RR: relative risk; CVP: central venous pressure; INR: international normalized ratio; ALT: alanine transaminase; BUN: Blood Urea Nitrogen. MCSD: mechanical circulatory support device Temporary devices Selection of strategies for temporary mechanical circulatory support devices Temporary MCSD can be used for hemodynamic and clinical stability restoration, aiming at improvement of cardiac function and transplantation. Three strategies (which may be overlapped) can be defined: 1. Bridge to decision : should be considered in severely ill patients, who requires immediate hemodynamic support due to high risk of cardiac failure. It may occur in different situations – lack of neurological recovery, multiple organ failure, hemodynamic stabilization and requirement of other devices – in which the final strategy of therapy cannot be established during device implantation (e.g. after cardiorespiratory arrest). 22 2. Bridge to recovery: situation in which support device is removed for ventricular function recovery, such as ventricular dysfunction following acute myocardial infarction, Takotsubo cardiomyopathy and myocarditis. 23 5