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Review
. 2022 Sep 6;12(9):1463.
doi: 10.3390/jpm12091463.

Left Ventricular Unloading in Acute on Chronic Heart Failure: From Statements to Clinical Practice

Alice Sacco  1 , Nuccia Morici  2 , Jacopo Andrea Oreglia  1 , Guido Tavazzi  3   4 , Luca Villanova  1 , Claudia Colombo  1 , Laura Garatti  1 , Michele Giovanni Mondino  1 , Stefano Nava  1 , Federico Pappalardo  5
Affiliations
Review

Left Ventricular Unloading in Acute on Chronic Heart Failure: From Statements to Clinical Practice

Alice Sacco et al. J Pers Med. .

Abstract

Cardiogenic shock remains a deadly complication of acute on chronic decompensated heart failure (ADHF-CS). Despite its increasing prevalence, it is incompletely understood and therefore often misdiagnosed in the early phase. Precise diagnosis of the underlying cause of CS is fundamental for undertaking the correct therapeutic strategy. Temporary mechanical circulatory support (tMCS) is the mainstay of management: identifying and selecting optimal patients through understanding of the hemodynamics and a prompt profiling and timing, is key for success. A recent statement from the American Heart Association provided pragmatic suggestions on tMCS device selection, escalation, and weaning strategies. However, several areas of uncertainty still remain in clinical practice. Accordingly, we present an overview of the main pitfalls that can occur during patients' management with tMCS through a clinical case. This case illustrates the strict interdependency between left ventricular unloading and right ventricular dysfunction in the case of low filling pressures. Moreover, it further illustrates the pivotal role of stepwise escalation of therapy in a patient with an ADHF-CS and its peculiarities as compared to other forms of acute heart failure.

Keywords: acute on chronic heart failure; cardiogenic shock; escalation; mechanical circulatory support.

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Conflict of interest statement

N.M. received institutional grant support from Getinge Global US; F.P. is a consultant for Abiomed. The remaining authors have nothing to disclose.

Figures

Figure 1
Figure 1
Hemodynamic profiles after Impella placement. Hemodynamics deterioration (panel A); normalization of pulmonary pressures and hemodynamics stabilization after the patient started mechanical ventilation with inhalation of 20 parts per million of nitric oxide (panel B and C); clinical picture deterioration (panel D and E) being refractory to further increase of inotropes. HR = heart rate; SBP = systolic blood pressure; DBP = diastolic blood pressure; sPAP = systolic pulmonary artery pressure; dPAP = diastolic pulmonary artery pressure; RAP = right atrial pressure; EtCO2 = end-tidal CO2; RR = respiratory rate.
Figure 2
Figure 2
Decisional algoritm in CS. LV = left ventricle; ECMO = venoarterial extracorporeal membrane oxygenation; IABP = intraortic balloon counterpulsation.
See this image and copyright information in PMC

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