EACTS/STS/AATS Guidelines on temporary mechanical circulatory support in adult cardiac surgery
Introduction
Temporary mechanical circulatory support (tMCS) has evolved
significantly over the past decade. The distinction between temporary
and durable mechanical circulatory support (dMCS) is
based on discharge potential: Patients supported with tMCS are
not eligible for hospital discharge. Modern tMCS devices demonstrate
improved haemocompatibility and significantly reduced
device-related complications compared to earlier generations.
Enhanced safety and broader clinical applicability have led to
wider adoption. Notably, use of microaxial flow pumps (mAFPs)
and extracorporeal life support (ECLS) has increased substantially.
2,3 In the United States, changes to the donor heart allocation
system have led to a sharp rise in tMCS use as a bridge to a
transplant (BTT),4,5 and the number of patients bridged to a
heart transplant (HTx) with tMCS has tripled since 2018.5 Similar
trends have been observed internationally.6–8
tMCS is now a standard of care for managing acute cardiogenic
shock (CS),9–11 acute-on-chronic heart failure (HF),12–14
and circulatory failure following cardiac procedures.1,15
Moreover, broader availability of mAFP devices and growing
clinical expertise have enabled tMCS use in increasingly complex
scenarios, including in elderly and paediatric patients,16 those
with adult congenital heart disease (ACHD), and individuals
undergoing complex cardiac operations or presenting with
advanced CS. This progress has been made possible through
increased research efforts. Although conducting a randomized
controlled trial (RCT) in this setting remains extremely challenging,
particularly due to the short time frame between patient
presentation and the need for intervention, ethical concerns,
and the heterogeneity of clinical scenarios, several recently conducted
trials in acute myocardial infarction (AMI) have demonstrated
that well-designed multicentre studies are not only
feasible but also essential to better understand the safety and efficacy
of available therapeutic modalities.17,18
Today, the field has evolved from a “one-size-fits-all” ECLS
model to a modular, scenario-specific use of tMCS devices with
varying mechanisms and levels of invasiveness. Although this
shift has facilitated individualized care, it has also increased
complexity across all phases of management, from indication to
postoperative care. This guideline addresses these challenges
and supports standardized approaches regarding indication,
implanting techniques, management, weaning, and end-of-life
(EOL) treatment.
Following its previous publications on long-term MCS and
post-cardiotomy ECLS,1,19 the EACTS, in partnership with STS
and AATS, now presents these joint guidelines on tMCS. A companion
document on “protected cardiac surgery” was recently
published,20 making this guideline a natural extension of ongoing
collaborative efforts to improve patient care in this rapidly
evolving field.
These guidelines do not cover tMCS use in elective interventional
procedures such as “protected percutaneous coronary
intervention” (PCI) or “protected transcatheter mitral valve
replacement” in stable patients. They also exclude veno-venous
(VV)-ECLS for isolated lung failure, which is addressed in
anaesthesia-led guidelines.21 tMCS use in paediatric populations
will be the focus of a future joint document.
Management of patients with tMCS requires collaboration
among surgeons, anaesthesiologists, intensive care specialists,
and cardiologists. This interdisciplinary approach is a key pillar
of the present expert consensus, which includes contributors
from all relevant specialties. However, it is critical to emphasize
that delayed or absent deployment of tMCS remains a major
threat to patients with CS. While interdisciplinary decision making
is ideal, it must never delay life-saving therapy.
This document includes both surgical guidance (for implants
and explants) and medical management (device selection, intensive
care, transport, weaning, and palliative care), providing a
comprehensive framework for all aspects of tMCS therapy.