Role of acute mechanical circulatory support devices in cardiogenic shock

Abstract

Cardiogenic shock is a state of low cardiac output that is associated with significant morbidity and mortality. A considerable proportion of patients with cardiogenic shock respond poorly to medical management and require acute mechanical circulatory support (AMCS) devices to improve tissue perfusion as well as to support the heart. In the last two decades, many new AMCS devices have been introduced to support the right, left, and both ventricles. All these devices vary in terms of the support they provide to the body and heart, mechanism of functioning, method of insertion, and adverse events. In this review, we compare and contrast the available percutaneous and surgically placed AMCS devices used in cardiogenic shock and discuss the associated clinical and hemodynamic data to make a conscious decision about choosing a device.

Keywords: Acute mechanical circulatory support (AMCS) devices; Cardiogenic shock; Low cardiac output.

Fig. 1

Diagnosis and management of cardiogenic shock

Fig. 2

Choice of the right MCS should be guided by patient phenotype, hemodynamic needs, risk of complication, and AMCS availability. IABP is marked in green suggesting that it can be AMCS in any patient until further decision is made. Typical needs for patients based on phenotype are highlighted in red for left heart and blue for right heart. Most patients usually require peri-procedural AMCS for 1–3 L/min of support, whereas patients presenting in cardiogenic shock typically require 3–5 L/min of support. AMCS should be chosen accordingly. Patients with decompensated HF often can be treated quickly with medical therapy or an IABP; however, in patients with significant end-organ hypoperfusion, complete hemodynamic support is often needed

Fig. 3

Left ventricular venting and unloading in a patient on VA-ECMO. VA-ECMO, veno-arterial extracorporeal membrane oxygenation; CVVHD, continuous veno-venous hemodialysis; echo, echocardiography; LV, left ventricle; RSPV, right superior pulmonary vein; MPA, main pulmonary artery; IABP, intra-aortic balloon pump

Fig. 4

Decision making and choosing the AMCS in patients with AMI-CS and complications of AMI. CS, cardiogenic shock; AMI, acute myocardial infarction; ECG, electrocardiography; PCI, percutaneous coronary intervention; Echo, echocardiography; GMDT, guideline-directed medical therapy; LV, left ventricle; VSD, ventricular septal defect; BiV, biventricular; VA-ECMO, veno-arterial extracorporeal membrane oxygenation; MR, mitral regurgitation

Fig. 5

Decision making and choosing the AMCS in patients with non-AMI-CS. CS, cardiogenic shock; AMI, acute myocardial infarction; ABG, arterial blood gas; VBG, venous blood gas; RFT, renal function test; LFT, liver function test; SCAI, Society of Cardiovascular Angiography and Interventions; OMT, optimal medical therapy; LVOT, left ventricular assist device; VT, ventricular tachycardia; VF, ventricular fibrillation; oxy-RVAD, right ventricular assist device with oxygenator

Fig. 6

Decision making in escalation of AMCS device. AMCS, acute mechanical circulatory support; LV, left ventricle; RV, right ventricle; VA-ECMO, veno-arterial extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; oxy-RVAD, right ventricular assist device with oxygenator; LVAD, left ventricular assist device

Fig. 7

Decision making in de-escalation of AMCS devices. AMCS, acute mechanical circulatory support; LV, left ventricle; RV, right ventricle; VA-ECMO, veno-arterial extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; oxy-RVAD, right ventricular assist device