ABC | Volume 111, Nº1, July 2018

Special Article Ayub-Ferreira Guidelines for MCS of the BSC Arq Bras Cardiol. 2018; 111(1):4-12 Figure 1 – Progress of long-term mechanical circulatory support devices. 1 st generation 2 nd generation 3 rd generation • Pulsatile flow • Valves • Mechanical rotator • Continuous flow • Axial • Mechanical axis • Continuous flow • Centrifugal • Non-contact bearing • Magnetic or Hydrodynamic levitation Chart 6 – Long-term mechanical circulatory support devices available in Brazil Name Company Type of pump Type of support Presence of bearing Anvisa Approval HeartMate II ® Thoratec Axial flow Left Yes Yes INCOR ® Berlin Heart Axial flow Left No (electromagnetic levitation) Yes HeartWare ® HeartWare Centrifugal flow Left No (electromagnetic levitation) Yes Anvisa: Agência Nacional de Vigilância Sanitária (The Brazilian Health Regulatory Agency); NA: not applicable Recommendations for long-term mechanical circulatory support devices as bridge to decision Recommendation Class Level of evidence Systolic heart failure - INTERMACS 2 and 3 Class IIa C Systolic heart failure - INTERMACS 4 Class IIb C Systolic heart failure - INTERMACS 1, 5, 6 and 7 Class III C Patients eligible for MCSD should be evaluated for the presence of factors that may contraindicate or negatively influence patients’ survival after transplant. Main contraindications are listed in Chart 7. Strategy for selection of long-term MCSDs 1. Bridge to decision: long-termMCSDs may be indicated for patients with clinical conditions that contraindicate heart transplantation, but if modified, patients may become eligible for transplant (for example: pulmonary hypertension and curable cancers). 2. Bridge to transplant: Situations in which MCSDs may provide hemodynamic support and clinical stability until heart transplant, in patients with progressive severity and when a short-term transplant is not possible. 3. Destination therapy: Situations in which MCSDs may provide hemodynamic support and clinical stability in patients with refractory heart failure with contraindication for cardiac transplant, promoting higher survival and better quality of life as compared with clinical treatment with drugs. Optimization andmanagement of right ventricular function Right ventricular failure is still one of the main factors that affect patients’ survival after MCSD implantation. 28 Its diagnostic criteria are – signs and symptoms for persistent right ventricular dysfunction; CVP > 18 mmHg with cardiac index < 2,0 L/min.m 2 in the absence of ventricular arrhythmias or pneumothorax; requirement of ventricular support devices; or requirement for inhaled nitric oxide or inotropic therapy for more than one week after device implantation. 29 Implantation of a MCSD increases cardiac output and consequently causes an increment in venous return to the right ventricle. To counteract this preload increase, right ventricular compliance should improve with reduction of its afterload (decrease in left ventricular filling pressure and pulmonary arterial pressure). However, leftward shift of IVS may occur in case of excessive left ventricular emptying. 29 In addition to its contractility, optimization of right ventricular preload and afterload is crucial to prevent right ventricular failure in the perioperative period. CVP and systolic pulmonary pressure should be maintained lower than 16 mmHg and 65 mmHg , respectively. For maintenance of coronary perfusion, use of inotropes that cause pulmonary vasodilation (milrinone or dobutamine) and maintain adequate systemic pressure (adrenaline) is recommended. In addition, the use of specific pulmonary vasodilators, such as nitric oxide should be considered (Figure 2). 30 Complications after long-term MCSD implantation The main complications related to long-term MCSD implantation are described in Chart 8. Proposal of prioritization criteria for cardiac transplant in patients with MCSD With increasing number of MCDSs, this document proposes a change in the prioritization criteria for patients in the cardiac transplant waiting list. These new criteria are described in Chart 9. 9