Correspondence from the world of cardiology
Dear Sirs,
We would like to thank Professor Stephen Westaby for his interesting editorial1 on mechanical circulatory support in the setting of the National Institute for Health and Care Excellence (NICE) guidelines on acute heart failure. He discusses two examples of patients who were not served well by the current commissioning arrangements in place for acute heart failure and longer term ventricular assist device (VAD) destination therapy, and argues compassionately for a widening of access to technologies such as extracorporeal membrane oxygenation (ECMO) and left VAD (LVAD) to support patients where required.
We could not agree more. Within our own institution, King’s College Hospital, London, a tertiary cardiovascular centre, cardiac arrest centre and major emergency department, the critical care ECMO service offers temporary mechanical circulatory support to patients with refractory cardiac arrest or cardiogenic shock. In just over two years, we have undertaken either extracorporeal cardiopulmonary resuscitation (n = 13) or veno-arterial (VA) ECMO (n = 15) on 28 patients (mean age 42 years, range 15–64 years). All patients were INTERMACS 1 (Interagency Registry for Mechanically Assisted Circulatory Support), moribund on supra-maximal critical care support in multi-organ failure, or dead at the time of institution of extracorporeal life support (ECLS); for 26 out of these 28 patients (93%), seven were out of hospital cardiac arrests, 17 were in hospital cardiac arrests and two were failure to wean from cardiopulmonary bypass.
The wean rate from ECLS was 64% with a survival to hospital discharge of 50% with good neurological outcomes (as assessed by cerebral performance categories with 12 [86%] having the best outcome of 1 on the cerebral performance category [CPC] scale and the remaining being 2 on the CPC scale). All the survivors, except one who died following biventricular assist device implantation after transfer, are still alive and independent, and only one patient required heart transplantation at another institution. Three of those who did die, however, despite being weaned from VA ECMO, were declined transfer for consideration of longer term VAD destination therapy although they would surely have been considered for this in Europe and the USA.
If our experience is replicated in other major acute hospitals, as is likely, there is a significant potential to impact on the mortality of these young patients who have few other options. As Professor Westaby points out, these technologies cannot be restricted to only centres offering transplantation. They also need to be available in major acute provider centres. We agree that the government and commissioners need to address this shortfall in both facilities and equality in access urgently.
We would welcome cross-site discussions on building a pathway for these patients right from their presentation at major emergency departments and tertiary referral cardiac centres through to the supra-regional cardiac transplant centres.
Conflict of interest
None declared.
Robert Loveridge
Consultant in Intensive Care Medicine
Sameer Patel
Consultant in Intensive Care Medicine
Georg Auzinger
Consultant in Intensive Care Medicine
Julia Wendon
Consultant in Intensive Care Medicine
King’s College Hospital NHS Foundation Hospital (King’s Health Partners), Denmark Hill, London, SE5 9RS.
Reference
1. Westaby S. NICE guidelines for acute heart failure: long on pills, short on pumps. Br J Cardiol 2015;22:47−9. http://dx.doi.org/10.5837/bjc.2015.014
