Perioperative Mechanical Circulatory Support for Cardiac Assistance in Thoracic Surgery: A Scoping Review

Abstract

Background: Patients with pre-existing severe cardiovascular comorbidities are often deemed ineligible for potentially life-saving thoracic surgeries and are referred to other conservative therapies. However, this patient population may theoretically benefit from the timely perioperative implantation of temporary mechanical circulation support (tMCS) to both mitigate the surgical stress and stabilize hemodynamics. We performed a scoping review to summarize the evidence regarding the use of tMCS in thoracic surgery.

Methods: We conducted a systematic search across PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Google Scholar from their inception, aided by a search string encompassing a combination of terms for the key research concepts: i) tMCS devices; ii) thoracic surgery procedures (except lung transplantation); and iii) the adult population.

Results: Fifteen studies pertinent to the research question, which summarized data from 28 patients, were retrieved for inclusion. In 14 patients, tMCS implantation occurred as a "pre-emptive" strategy, while the remaining patients had tMCS implanted either intra and/or postoperatively as a "bail-out" strategy. Specifically, 14 patients required an intra-aortic balloon pump, 10 veno-arterial extracorporeal membrane oxygenation, two required a multidevice strategy, and one cardiopulmonary bypass. The relative risk analysis revealed that the mortality rate in the pre-emptive group was half that of the bail-out group. Additionally, the risk of both infectious and vascular complications was lower in the pre-emptive group compared to the bail-out tMCS strategy.

Conclusion: We found that the timely implantation of tMCS in thoracic surgery-either to mitigate patients' heightened cardiovascular risk or as a rescue strategy in the event of life-threatening surgical complications-may lead to better patient outcomes, as well as allowing them to undergo curative surgery with an acceptable safety profile, characterized by overall good survival rates and a low incidence of device-related complications.

Keywords: cardiac assistance; cardiac failure; noncardiac surgery; perioperative; temporary mechanical circulatory support; thoracic surgery.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) 2020 flow diagram for the study selection process. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Schematic representation of the type of temporary mechanical circulatory support (tMCS) described in the selected studies, primarily classified based on the timing and implantation strategy (i.e., pre‐emptive or bail‐out). CPB, cardiopulmonary bypass; IABP, intra‐aortic balloon pump; pt(s), patient(s); tMCS, temporary mechanical circulatory support; VA‐ECMO, veno‐arterial extracorporeal membrane oxygenation.

FIGURE 3

Relative risk of postoperative complications in the pre‐emptive tMCS group versus bail‐out. The vertical line at 1.0 indicates no difference in risk between groups, while error bars represent 95% confidence intervals. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 4

Visual abstract presenting main article structure, objective, research methodology, and results. CPB, cardiopulmonary bypass; IABP, intra‐aortic balloon pump; tMCS, temporary mechanical circulatory support; VA‐ECMO, veno‐arterial extracorporeal membrane oxygenation. [Color figure can be viewed at wileyonlinelibrary.com]