MCS current practice and weaning: CCCTN survey of CICU directors at academic medical centers

Abstract

Abstract Background/Introduction As the treatment of cardiogenic shock evolves, temporary mechanical circulatory support (MCS) use is increasing. Few studies have examined Cardiac Intensive Care Unit (CICU) practices for management and weaning of MCS. Purpose We aimed to describe current management and weaning practices for patients supported with an intra-aortic balloon pump (IABP) or Impella in CICUs. Methods During December 2022, a 45-question survey was electronically distributed by the Critical Care Cardiology Trials Network (CCCTN) to the CICU directors of 44 academic medical centers in North America. Descriptive statistics were used to summarize the results. Results A response rate of 84% was achieved. Among respondents, CICU bed capacity ranged from 8-32 (Mean of 17). Staffing was primarily by cardiologists without board certification in heart failure or critical care (38%). One-in-four centers reported staffing by a multi-disciplinary team consisting of cardiologists and intensivists. Most centers use heparin anticoagulation for both IABP (32, 87%) and Impella (32, 91%) and primarily used PTT to monitor anticoagulation (23, 62%) with a target of 50-70 seconds (27, 73%). While using Impella support, daily TTE (29%), plasma free hemoglobin measurements (34%) and prophylactic antibiotics (3%) were uncommon. Most institutions did not have a formal weaning protocol for IABP (78%) or Impella (66%). The majority of centers reported IABP weaning to be a subjective decision led by the CICU attending (65%), while Impella weaning was commonly a decision made by a multi-disciplinary team including the CICU attending (57%). PACs are used routinely when weaning Impella (83%) but not IABP (46%). IABP removal is most commonly done at bedside by CICU team (70%), whereas Impella removal is most commonly done in the catheterization laboratory (43%). Conclusions In this survey of academic CICUs, IABP and Impella management showed substantial variability across centers. Use of invasive hemodynamic monitoring was common but its use during weaning was not uniform. Multidisciplinary involvement was more common with Impella support and weaning when compared to IABP. These heterogeneous results highlight the need for further investigation to guide best practices in MCS management.