2. INTRODUCTION
Long-term durable mechanical circulatory support (LT-MCS) has evolved significantly in the last decade. Today’s devices have become more reliable, and their durability has increased whereas device-related complications have drastically decreased compared with earlier generations of devices. In addition to a growing population with end-stage heart failure (HF), these developments have led to a notable increase in MCS implants, particularly of continuous-flow left ventricular assist devices (CF-LVADs). In Germany only, nearly 1000 LVADs were implanted in 2016 [1]. Thus, LT-MCS has become a standard of care in the treatment of end-stage HF. Moreover, the availability of smaller blood pumps together with growing clinical experience has expanded the target population by extending LT-MCS to patients with more complex conditions, including elderly and paediatric patients, patients with congenital heart defects and patients with advanced comorbidities. This expansion has resulted in a significant increase in the complexity of all aspects of management of these patients from selection to postoperative management, which is recognized in the presented consensus statement.
The European Association for Cardio-Thoracic Surgery (EACTS) has not recently provided guidance on LT-MCS. However, since the available scientific evidence consists mainly of observational studies with a few randomized clinical trials, it would not be feasible to formulate a full set of guidelines that meets EACTS criteria. Therefore, the EACTS provides an expert consensus statement in this document.
In this statement, we have generally refrained from using the designations of bridge to transplant and destination therapy in accordance with the more recent randomized trials in this field [2a]. This decision relates to the fact that, although a cardiac transplant is intended in the majority of LT-MCS recipients, only a minority will ever receive a donor organ in Europe. In a recent report of the ELEVATE (Evaluating the HeartMate 3 with Full MagLev Technology in a Post-Market Approval Setting) registry of more than 450 consecutive patients (mainly European) undergoing implantation of LT-MCS, only 2% received a transplant after 1 year, despite 26% of the patients receiving an implant as a destination therapy strategy [2b]. The latter also underscores the need for guidance of long-term management of MCS recipients, which consequently is an integral part of this statement.
As is stated in the present expert consensus, the multidisciplinary team of surgeons, intensive care specialists, cardiologists, perfusionists, LT-MCS coordinators, psychologists and other allied health care professionals should be involved in all stages of treatment of patients with LT-MCS. This goal is evident in the present expert consensus, which includes authors drawn from all the different specialties involved in the care of the patients with MCS. Furthermore, the chapters focusing on surgical aspects are complemented by chapters on medical management including patient selection, preoperative optimization, intensive care, ambulatory care and, finally, palliative care (PC).