Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock

Abstract

Objective To review temporary percutaneous mechanical circulatory support devices (pMCS) for the treatment of cardiogenic shock, including current evidence, contraindications, complications, and future directions. Data Sources A MEDLINE search was conducted with MeSH terms: cardiogenic shock, percutaneous mechanical circulatory support, extracorporeal membrane oxygenation (ECMO), Impella, and TandemHeart. Study Selection Selected publications included randomized controlled trial data and observational studies describing experience with pMCS in cardiogenic shock. Data Extraction Studies were chosen based on strength of association with and relevance to cardiogenic shock. Data synthesis Until recently, there were few options if cardiogenic shock was refractory to vasopressors or intra-aortic balloon pump (IABP) counterpulsation. Now, several pMCS devices, including Impella®, TandemHeart™, and ECMO, are more accessible. Compared with IABP, Impella provides greater hemodynamic support, but no reduction in mortality. Similarly, TandemHeart improves hemodynamic variables, but not survival. Comparative studies have been underpowered for mortality because of small sample size. Veno-arterial ECMO offers the advantage of biventricular circulatory support and oxygenation but there are significant vascular complications. Comparative studies with ECMO have not been completed. Despite lack of randomized controlled data, there has been a substantial increase in use of pMCS. Several ongoing prospective studies with larger sample sizes may provide answers, and newer devices may become smaller, easier to insert, and more effective. Conclusions Mortality from cardiogenic shock remains unacceptably high despite early coronary revascularization or other therapies. While evidence is lacking and complications rates are high, improvements and experience with pMCS may offer the prospect of better outcomes.

Post-transplant outcome in patients bridged to transplant with temporary mechanical circulatory support devices

“…Even though both support strategies provide a similar degree of hemodynamic support, they each have a unique adverse event profile. 32,33 The rapidity of deployment of ECMO offers advantages over the surgically implanted T-BiVAD, as early hemodynamic support in patients with cardiogenic shock confers improved survival. 34,35 However, the early stabilization benefit offered by ECMO does not seem to translate to the post-transplant period in patients where a decision is made to proceed to transplant while on ECMO.…”

Con: Impella Mechanical Circulatory Support Is Preferable to Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock

“…Barriers to use include bulky circuitry, higher rate of vascular complications compared with other MCS devices, need for greater levels of anticoagulation, risk of hemorrhage, and altered physiology that may impede recovery of the failing left ventricle. 3,28,29 Peripheral VA ECMO often is established by accessing the femoral or internal jugular vein with an 18 to 21 F venous inflow cannula. The aspirated blood is circulated through a membrane oxygenator-heater and is returned to the systemic arterial vasculature via the aid of a nonpulsatile centrifugal pump.…”

“…To prevent these complications, venting of the left ventricle is encouraged when VA ECMO is used. 3,28 Use of Impella devices to reduce left ventricular distention in patients on VA ECMO has been described. This concept of ECMELLA has been shown to decrease mortality significantly.…”

A Review of percutaneous mechanical support devices and strategies

“…Since the pre-reperfusion era, our understanding of the pathophysiology of cardiogenic shock has evolved. Unfortunately, despite advances in protocols, reperfusion strategies, percutaneous coronary intervention (PCI), and pharmacotherapy, the mortality for patients with the most severe forms of shock still remains high (Miller et al, 2017).…”