Percutaneous Mechanical Circulatory Support Devices in Cardiogenic Shock

Abstract

Despite a high rate of early revascularization and use of intraaortic balloon pump counterpulsation (IABP) therapy, the prognosis of patients with cardiogenic shock (CS) has remained poor. In the hopes of improving outcomes, clinicians are increasing turning to percutaneous left- and right- mechanical circulatory support devices. Until recently, the evidence base for these devices had consisted only of observational data, meta-analyses, and small feasibility trials. In this manuscript, we describe the contemporary outcomes of patients with CS, the hemodynamics of CS, and hemodynamic effects of percutaneous mechanical circulatory support devices. We then use this discussion to provide clinicians with a useful framework for understanding when selecting between or while managing patients with a percutaneous mechanical circulatory support devices. We critically review the recently published data for and against the use of commercially-available devices – the IABP, the Impella system, the TandemHeart, and V-A ECMO - and highlight gaps in our understanding. Given such gaps, a consensus multidisciplinary approach which combines expertise from interventional cardiologists, heart failure specialists, cardiac surgeons, and cardiac anesthesiologists may help pair the right patient with the right device at the right time.

Outcomes of patients with cardiogenic shock treated with TandemHeart® percutaneous ventricular assist device: Importance of support indication and definitive therapies as determinants of prognosis

“…Cardiogenic shock is caused by numerous conditions including acute myocardial infarction (AMI), fulminant myocarditis, end stage cardiomyopathy, severe valvular dysfunction, and refractory arrhythmias. Although the mortality for cardiogenic shock has decreased in the modern era with the widespread implementation of percutaneous coronary intervention (PCI) for AMI, improved medical therapy and development of mechanical circulatory support (MCS) devices, the in‐hospital mortality still remains high at nearly 50% .…”

Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno‐arterial extracorporeal membrane oxygenation for critical cardiogenic shock

“…Risk factors for survival from cCS requiring pVA‐ECMO have been well studied . However, clinical data describing factors that affect myocardial recovery in these patients are scarce, despite increasing use of pVA‐ECMO and drastic consequences in cases of failed myocardial recovery . Using a retrospective cohort, we have therefore developed a prediction model to assess risk factors of transition to dMCS in patients with cCS requiring pVA‐ECMO.…”

“…Peripheral veno‐arterial extracorporeal membrane oxygenation (pVA‐ECMO) has gained increasing value in an attempt to improve outcomes from critical cardiogenic shock (cCS). The rationale behind pVA‐ECMO is to allow for myocardial recovery while limiting secondary end‐organ damage …”

“…The rationale behind pVA-ECMO is to allow for myocardial recovery while limiting secondary end-organ damage. 1,2 The vast majority of studies assessing the outcomes from cCS requiring pVA-ECMO and its associated risk factors have focused almost exclusively on (hospital) survival. [3][4][5] Only very little clinical data is available with respect to myocardial recovery and its underlying mechanisms.…”

Integrating invasive hemodynamic parameters into risk stratification of acute myocardial infarction and cardiogenic shock

“…Timely identification and mechanical reperfusion of STEMI contributed to a substantial decline in the morbidity and mortality associated with such condition overtime . Cardiogenic shock (CS) may complicate up to 10% of STEMI cases and is associated with a 30‐day mortality of up to 50% despite early mechanical reperfusion . While several innovative mechanical circulatory support (MCS) devices have been recently developed, the evidence for or against and the timing of their use remain inconclusive .…”