From medical therapy to mechanical support: strategies for device selection and implantation techniques

Abstract

Cardiogenic shock (CS) is a complex clinical syndrome with a high risk of mortality. The recent, rapid development of temporary mechanical circulatory support (tMCS) has altered CS treatment. While catecholamines remain the cornerstone of CS therapy, tMCS usage has increased. According to shock severity, different treatment strategies including catecholamines alone, catecholamines and tMCS, or multiple tMCS might be used. State-of-the-art implantation techniques are necessary to avoid complications linked to the invasive nature of tMCS. In particular, bleeding and access-site complications might counteract the potential haemodynamic benefit of a percutaneous ventricular assist device. In this review, we describe the role of catecholamines in CS treatment and present the different tMCS devices with an explanation on how to use them according to CS aetiology and severity. Finally, an overview of the best practice for device implantation is provided.

Percutaneous Mechanical Circulatory Support in Acute Heart Failure Complicated with Cardiogenic Shock

“…The data comparing various supportive therapies exhibit inconsistencies, with none proving significantly beneficial in terms of major outcomes. Levosimendan seems to be the sole agent demonstrating a potential decrease in mortality compared to a placebo during the early stages of CS, even though it is not included in the current guidelines with a level of evidence [5,6]. However, it does not show a benefit when compared to other inotropes.…”

“…However, it does not show a benefit when compared to other inotropes. Existing evidence regarding vasopressors indicates that norepinephrine may be linked to lower mortality rates, compared with dopamine or epinephrine [5,7,8]. PDE3 inhibitors can also be used in patients characterized by the absence of ischemia [3].…”

“…Bleeding incidents can be categorized into access-site and non-access-site bleeding. The latter is associated with factors such as thrombocytopenia, sepsis, shear-stress-induced acquired von Willebrand syndrome, and the administration of anticoagulation therapies [5]. The axial flow Impella devices, unlike the pulsatile iVAC, come with the drawback of a substantially higher risk of hemolysis (seen in 10% of patients within the first 24 h) due to the rapid rotation of the axial flow pump [66][67][68][69][70].…”

“…Specifically, in VA-ECMO or ECMELLA, it becomes imperative to use antegrade perfusion techniques to ensure sufficient blood flow to the distal limb. When encountering limb ischemia with the exclusive use of mAFP, it may be advisable to investigate vasospasm as a potential cause of ischemia [5].…”