British societies guideline on the management of emergencies in implantable left ventricular assist device recipients in transplant centres.

An implantable left ventricular assist device (LVAD) is indicated as a bridge to transplantation or recovery in the United Kingdom (UK). The mechanism of action of the LVAD results in a unique state of haemodynamic stability with diminished arterial pulsatility. The clinical assessment of an LVAD recipient can be challenging because non-invasive blood pressure, pulse and oxygen saturation measurements may be hard to obtain. As a result of this unusual situation and complex interplay between the device and the native circulation, resuscitation of LVAD recipients requires bespoke guidelines. Through collaboration with key UK stakeholders, we assessed the current evidence base and developed guidelines for the recognition of clinical deterioration, inadequate circulation and time-critical interventions. Such guidelines, intended for use in transplant centres, are designed to be deployed by those providing immediate care of LVAD patients under conditions of precipitous clinical deterioration. In summary, the Joint British Societies and Transplant Centres LVAD Working Group present the UK guideline on management of emergencies in implantable LVAD recipients for use in advanced heart failure centres. These recommendations have been made with a UK resuscitation focus but are widely applicable to professionals regularly managing patients with implantable LVADs.

Mechanical life support algorithm for the emergency management of patients with left-sided Impella.

We sought to remedy the limited guidance that is available to support the resuscitation of patients with the Impella Cardiac Power (CP) and 5.0 devices during episodes of cardiac arrest or life-threatening events that can result in haemodynamic decompensation. In a specialist tertiary referral centre we developed, by iteration, a novel resuscitation algorithm for Impella emergencies, which we validated through simulation and assessment by our multi- disciplinary team. A mechanical life support course was established to provide theoretical and practical education, combined with simulation to consolidate knowledge and confidence in algorithm use. We assessed these measures using confidence scoring, a key performance indicator (the time taken to resolve a suction event) and a multiple-choice question (MCQ) examination. Following this intervention, median confidence score increased from 2 (interquartile range [IQR] 2 to 3) to 4 (IQR 4 to 4) out of a maximum of 5 (n=53, p<0.0001). Theoretical knowledge of the Impella, as assessed by median MCQ score, increased from 12 (IQR 10 to 13) to 13 (12 to 14) out of a maximum of 17 (p<0.0001). The use of a bespoke Impella resuscitation algorithm reduced the mean time taken to identify and resolve a suction event by 53 seconds (95% confidence interval 36 to 99, p=0.0003). In conclusion, we present an evidence-based resuscitation algorithm that provides both technical and medical guidance to clinicians responding to life-threatening events in Impella recipients.