Percutaneous Mechanical Circulatory Support Devices in Cardiogenic Shock

Abstract

Despite a high rate of early revascularization and use of intra-aortic balloon pump counterpulsation therapy, the prognosis of patients with cardiogenic shock has remained poor. In the hopes of improving outcomes, clinicians are increasingly 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 article, we describe the contemporary outcomes of patients with cardiogenic shock, the hemodynamics of cardiogenic shock, 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 intra-aortic balloon pump counterpulsation, the Impella system, the TandemHeart, and venous-arterial extracorporeal membrane oxygenation-and highlight gaps in our understanding. Given such gaps, a consensus multidisciplinary approach that 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.

Keywords: cardiogenic shock; left ventricular dysfunction; mechanical circulatory support; percutaneous; right ventricular dysfunction.

Figure 1

We queried the 2004–2014 Nationwide Inpatient Sample databases to identify all patients with CS (ICD-9 CM 785.51). The Mantel-Haenszel X² test to analyze trends. (A) The overall incidence of CS increased from 55,123 discharges in 2004 to 126, 555 discharges in 2014 (p_trend = 0.002). (B) In-hospital mortality decreased from 62% in 2004 to 48% in 2014 (p_trend = 0.02).

Figure 2

Contemporary, commercially available percutaneous left- (Panel A) and right- (Panel B) ventricular mechanical support devices.

Figure 2

Contemporary, commercially available percutaneous left- (Panel A) and right- (Panel B) ventricular mechanical support devices.

Figure 3

We queried the 2004–2014 Nationwide Inpatient Sample databases to identify all patients undergoing ECMO (ICD-9 CM 39.65). The Mantel-Haenszel X² test was used to analyze trends. (A) ECMO was used in 1,653 patients in 2004 and 6,890 patients in 2014 (p_trend = 0.005). (B) In-hospital mortality was stable between 2004 and 2014 at 47% (p_trend = 0.80).