Practical tips:

• Vasopressors and positive inotropic agents remain the first lines of treatment, but frequently offer inadequate support; then, the use of percutaneous MCS in severe, refractory cardiogenic shock should be considered early in a patient’s clinical course.
• The choice of which MCS device to use is based on many factors, including patient characteristics, the degree of desired hemodynamic support, operator abilities, and institutional resources.
• In general, there is a continuum of increasing hemodynamic support from the IABP to the Impella 2.5 and CP devices to the TandemHeart and veno-arterial (VA) -ECMO.
• The choice of which device to use is multifactorial, based on patient characteristics, operator ability, and the degree of hemodynamic support desired.
• These devices are best managed with a care team approach that includes an advanced heart failure cardiologist.

In general, patients with HF are potentially candidates for MCS if they fulfill the Advanced HF criteria above.

Cardiac centres that perform MCS should have adequate manpower and resources for support of patients requiring MCS support. These include:

• An identified and adequately trained multidisciplinary MCS team;
• Access to the full array of medical and surgical consultative support, and institutional administrative and financial support;
• Expertise in MCS implantation, follow-up, and explantation.

Recommendation 64: We recommend that patients with either acute severe or chronic advanced HF and with an otherwise good life expectancy be referred to a fully equipped cardiac centre for assessment and management by a team with expertise in the treatment of severe HF, including mechanical circulatory support (MCS) (Strong Recommendation, Moderate Quality Evidence).

Recommendation 65: We recommend MCS be considered for patients who are listed for cardiac transplantation and who deteriorate or are otherwise not likely to survive until a suitable donor organ is found, including those for whom a long wait is expected (Strong Recommendation, High Quality Evidence).

Recommendation 66: We recommend that MCS be considered for patients for whom there is a contraindication for cardiac transplantation but may, via MCS, be rendered transplant eligible (Strong Recommendation, Low Quality Evidence).

Recommendation 67: We recommend that patients in cardiogenic shock be considered for temporary MCS to afford an opportunity for evaluation for long-term options (Strong Recommendation, Moderate-Quality Evidence).

• Extracorporeal Circulatory Membrane Oxygenator (ECMO) or other mechanical circulatory temporary devices should be preferred over IntraAortic Balloon Pump (IABP) except if the patient is suffering an acute ischemic event, as the increase in cardiac output offered by IABP is usually minimal.

Recommendation 68: We recommend permanent MCS be considered for highly selected transplant ineligible patients (Strong Recommendation, Moderate Quality Evidence).

Values and preferences: This recommendation places a high value on the potential variability of patient preference as well as the need to interact with the patient to ensure the choice reflects the patient’s values, with less value on the effectiveness of therapy

Recommendation 69: We recommend that institutions providing MCS therapy develop a policy regarding DT within the conventions, resources, and philosophy of care of their organization (Strong Recommendation, Low Quality Evidence).

Recommendation 70: We recommend that ambulatory patients with MCS therapy who are discharged from hospital and who have had minimal HF symptoms or ventricular arrhythmias for a period of at least 2 months be considered candidates for operation of a personal motor vehicle for a period not exceeding two thirds of the known battery charge time (Strong Recommendation, Low Quality Evidence).

Values and preferences: An objective assessment of the disease severity and prognosis for an individual patient by a validated scoring system is recommended. If the expected mortality is higher than procedural risk of advanced HF therapies, these patients should be considered for referral, provided they have a good life expectancy otherwise.

• The timing of discussions should strongly consider the high mortality rate in the year following a first HF hospitalization. A surrogate decision-maker should be identified early and regularly participate in these discussions.