Microcirculation in cardiogenic shock: from scientific bystander to therapy target

Abstract

Despite diagnostic and therapeutic improvements, mortality rates in patients with cardiogenic shock remain relatively high. Several studies showed that cardiogenic shock is associated with alterations in the microvascular circulation. These alterations may be reversed by extracorporeal support devices. A study by Munsterman and colleagues adds to the body of evidence showing that in patients deemed ready for discontinuing intra-aortic balloon pump (IABP) support, microcirculatory flow in small vessels increases after ceasing IABP therapy. This study not only highlights the need for optimal timing of weaning from IABP support but also supports recent findings that global hemodynamics do not necessarily result in changes of microvascular perfusion. All modalities of modern treatment in cardiogenic shock need to be evaluated for their effect on the microcirculation. Microcirculatory evaluations should be part of randomized controlled trial protocols. More effort is needed to improve outcomes and understand the microcirculation as a therapy target and not as a silent bystander.

Figure 1

Treatment strategies affecting macrovascular and microvascular perfusion in cardiogenic shock. Effect of treatment strategies on microcirculation: solid arrow, positive effect; dotted arrow, negative effect. ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump.