Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

Abstract

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.

Keywords: D(N)MCS; ELS; PC-ECLS; do-(not-)mechanical-circulatory-support; ethics; extracorporeal life support; post-cardiotomy extracorporeal life support.

Figure 1

Recommendations regarding informed consent for PC-ECLS. Abbreviations: CABG: coronary artery bypass grafting; TAVI: transcatheter aortic valve implantation; PC-ECLS: post-cardiotomy extracorporeal life support; D(N)MCS: do-(not-)mechanical-circulatory-support; LVEF: left ventricular ejection fraction; RV: right ventricle; HTx: heart transplant; SBP: systolic blood pressure; MCS: mechanical circulatory support; LVAD: left ventricular assist device; RHF: right heart failure. Captions: *Dilated ascending aorta, bicuspid aortic valve, coronary anatomy, small and calcified aortic annulus, redo operation, see: Raffa GM, et al. In-hospital outcomes after an emergency or prophylactic veno-arterial extracorporeal membrane oxygenation during transcatheter aortic valve implantation: a comprehensive review of the literature. Perfusion. 2019; #RHF denotes: right heart failure, see: Soliman O et al. Derivation and Validation of a Novel Right-Sided Heart Failure Model After Implantation of Continuous Flow Left Ventricular Assist Devices: The EUROMACS (European Registry for Patients with Mechanical Circulatory Support) Right-Sided Heart Failure Risk Score. Circulation 2018.