Recommendations for the Use of Mechanical Circulatory Support: Ambulatory and Community Patient Care: A Scientific Statement From the American Heart Association

echanical circulatory support (MCS) offers a surgical option for advanced heart failure when optimal medical therapy is inadequate.MCS therapy improves prognosis, functional status, and quality of life.1,2 The INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) tracks patient selection and outcomes for all implanted US Food and Drug Administration-approved MCS devices.From June 2006 until December 2014, >15 000 patients received MCS, and >2000 implantations are performed annually.One-year survival with current continuous-flow devices is reported to be 80%, and 2-year survival, 70%. 3 In patients awaiting heart transplantation, MCS provides a bridge to transplantation, and for others who are ineligible for heart transplantation, MCS provides permanent support or destination therapy.Indications and absolute and relative contraindications to durable MCS are listed in Table 1.As of July 2014, 158 centers in the United States offer long-term MCS. 3 Patients often live a substantial distance from the implanting center, necessitating active involvement of local first responders (emergency medical technicians, police, and fire department personnel), emergency department staff, primary care, and referring cardiologists.Because patients with MCS are becoming increasingly mobile, basic knowledge of equipment is necessary for personnel in public areas such as schools, public transportation, and airplanes/airports.Ambulatory patients with MCS can span the entire age spectrum from pediatrics to geriatrics.The aim of this document is to provide guidance for nonexperts in MCS and to facilitate the informed assessment, stabilization, and transport of the patient with MCS back to the MCS center for definitive therapy.In addition, the principles herein provide a foundation for emergency management and a framework to address the management of known MCS-associated complications and expected comorbid medical problems. EQUIPMENT OVERVIEWCurrently in the United States, the most frequently used durable devices are continuous-flow devices with axial (HeartMate II, St. Jude Corp, Minneapolis, MN) or centrifugal (HeartWare Ventricular Assist System, HeartWare Corp, Framingham, MA) flow (Figure 1A-1D).Excision of a round "core" from the left ventricular (LV) apex allows the device to be positioned within the LV.Anastomosis of the outflow cannula occurs at the ascending aorta.The pump is powered through the percutaneous lead (power cord) that exits through the abdominal wall.The percutaneous lead is attached to a controller that weighs between 1 and 1.5 lb, which operates the device and records data on operation.Typically, patients wear batteries during the day (lasting up to 12 hours) and plug into household power while their batteries charge at night.Practical field guides are available for further reference.4 All patients are issued a backup controller and spare batteries that they carry with them at all times.When transported to the emergency room, patients should