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 3 – Risk factors for right ventricular dysfunction after mechanical circulatory support device implantation (MCSD) 16 Indication of MCDS Destination therapy Sex Female Pre-implantation support Intra-aortic balloon pump and vasopressor requirement Organic dysfunctions Respiratory: invasive ventilatory support Hepatic: ALT ≥ 80 UI/L. bilirubin > 2.0 mg/dL Renal: serum creatinine ≥ 2.3 g/dL History of kidney replacement therapy Nutritional: albumin ≤ 3.0 g/dL Coagulation: platelets < 120,000 Others: increased BNP. PCR. Procalcitonin Right ventricular dysfunction Right ventricular diastolic diameter > 35 mm. FAC < 30%. Right atrium > 50 mm Hemodynamic measures CVP ≥ 15 mmHg or CVP/PCP ≥ 0.63. right ventricular work index ≤ 300 mmHg mL/m 2 ; low pulmonary artery pressures, low cardiac index or increased pulmonary vascular resistance Others Non-ischemic cardiomyopathy, reoperation, important TI, history of PTE ALT: alanine transaminase; BNP: brain natriuretic peptide; CRP: C-reactive protein; FAC: fractional area change; CVP: central venous pressure; PCP pulmonary capillary pressure; TI: tricuspid insufficiency; PTE: pulmonary thromboembolism Chart 4 – Main risk scores for right ventricular failure after left ventricular mechanical circulatory support device implantation Score Variables Prediction University of Michigan, RV Failure Risk Score, Matthews et al. 17 Vasopressor requirement: 4 points TGP ≥ 80 IU/L: 2 points Bilirubin ≥ 2.0 mg/dL: 2.5 points Creatinine ≥ 2.3 mg/dL or hemodialysis: 3 points Likelihood of right ventricular failure • ≥ 5.5 points: 7.6 • 4.0-5.0 points: 2.8 • ≤ 3.0 points: 0.49 Kormos et al. 18 Pre-operative predictors for early left ventricular dysfunction: CVP/PCP > 0.63 Ventilatory support BUN > 39 mg/dL One-year survival: • Absent right ventricular dysfunction: 78% • Early right ventricular dysfunction: 59% (p < 0.001) University of Pennsylvania, RV Failure Risk Score, Fitzpatrick et al. 19 Cardiac index ≤ 2.2 L/min/m 2 : 18 points SVRI ≤ 0.25 mmHg-L/m 2 : 18 points Important right ventricular dysfunction: 17 points Serum creatinine ≥ 1.9 mg/dL: 17 points Previous cardiac surgery: 16 points Systolic arterial pressure ≤ 96 mmHg: 13 points < 30: 96%, isolated left ventricular assist device ≥ 65 points: 11%, isolated left ventricular assist device CRITT score 20 CVP > 15 mmHg: 1 point Severe right ventricular dysfunction: 1 point Pre-operative mechanical ventilation: 1 point Important tricuspid insufficiency: 1 point Tachycardia (> 100 bpm) = 1 point 1-2 points: low risk for right ventricular dysfunction 2-3 points: moderate risk for right ventricular dysfunction 4-5 points: high risk for right ventricular dysfunction ALT: alanine transaminase; CVP: central venous pressure; PCP pulmonary capillary pressure; BUN: Blood Urea Nitrogen; SVRI: systemic vascular resistance index 3. Bridge to transplantation: situations in which the patient is in progressive severity and heart transplantation cannot be performed in a short term. Support devices may provide hemodynamic support and clinical stability until transplantation is performed. Types of temporary mechanical circulatory support devices Main characteristics of temporary MCSDs available in Brazil are described in Chart 5. 24 Indications and contraindications Although temporary MCSDs are primarily indicated for patients INTERMACS levels 1 and 2, INTERMACS level 3 patients, dependent of high doses of inotropes or at high risk of hemodynamic instability may also be considered eligible. Contraindications for temporary MCDS include limiting clinical situations that require individualized approach and involvement of other professionals (e.g. oncologist for establishment of cancer prognosis). Intra-aortic balloon pump (IABP) The mechanism of action of the IABP is aortic counterpulsation, which increases diastolic pressure at aortic root, promoting an increase in coronary perfusion, afterload reduction, and consequently an increment in cardiac output by 15%. 6