Short-term mechanical circulatory support (intra-aortic balloon pump, Impella, extracorporeal membrane oxygenation, TandemHeart): a review

Abstract

Cardiogenic shock remains a major cause of morbidity and mortality for patients with acute myocardial infarction and advanced heart failure. Intra-aortic balloon pump has been the most widely used short-term mechanical circulatory support device to rapidly stabilize hemodynamics. However, it provides modest support, current evidence does not show a decrease in mortality, and the latest guidelines no longer recommend its routine use. Several percutaneous mechanical circulatory support devices have been introduced into clinical practice (Impella, extracorporeal membrane oxygen, TandemHeart), providing a greater level of hemodynamic support. These resource-intensive devices demand a careful selection of patients that stand to benefit the most. Premature initiation of mechanical circulatory support exposes the patient to unnecessary risk, whereas delaying therapy leads to irreversible end-organ injury, rendering any intervention medically futile. Cannulation methods, pump designs, and circuit configurations differ between devices, as do the adverse effects and physiological impact on the myocardium, which needs to be factored into consideration before deployment on the patient in cardiogenic shock. This article will review the commonly used percutaneous mechanical circulatory support devices in the setting of cardiogenic shock, compare their advantages and disadvantages, evaluate key clinical trials, and discuss a practical approach to guide clinicians' decision and management.

Valvular complications following the Impella device implantation

“…The Impella can provide haemodynamic support similar to ventricular assist devices with the advantages of unloading the left ventricle and being miniaturized and able to be placed percutaneously (2.5, CP) 18 . By continuously aspirating blood from the left ventricle, the Impella has a beneficial effect on LV unloading, coronary flow, and overall cardiac output 19 .…”

“…As with other mechanical support devices, severe peripheral vascular disease is a relative contraindication for femoral access due to the risk of limb ischemia. The presence of a mechanical aortic valve is considered an absolute contraindication, while severe aortic stenosis as a relative contraindication 18 …”

“…Potential complications related to the use of Impella are device‐related, peripheral vascular, and distal thrombus formation with subsequent strokes. According to a recent report, the most common complications reported were bleeding requiring transfusion (17.5%), vascular access complications (15.2%), infection (12.9%), hemolysis (10.3%), vascular complications with a need of surgical repair (9.7%), limb ischemia (3.9%) and bleeding requiring surgical intervention (2.6%) 18,23 . Valvular complications included aortic and mitral valve injury or regurgitation.…”

Valvular Complications Following the Impella Device Implantation

“…The Impella can provide haemodynamic support similar to ventricular assist devices with the advantages of unloading the left ventricle and being miniaturised and able to be placed percutaneously (2.5, CP) [8]. By continuously aspirating blood from the left ventricle, the Impella has a beneficial effect on LV unloading, coronary flow, and overall cardiac output [9].…”

“…As with other mechanical support devices, severe peripheral vascular disease is a relative contraindication for femoral access due to the risk of limb ischaemia. The presence of a mechanical aortic valve is considered an absolute contraindication, while severe aortic stenosis as a relative contraindication [8].…”