The mechanical support of cardiogenic shock

Abstract

Purpose of review Cardiogenic shock (CS) therapy involving catecholamines, inotropes, fluids and revascularization is often insufficient, and short-term mortality remains 50%. Different treatment algorithms and mechanical circulatory support devices (MCS) have been increasingly used in the treatment of CS. Coronavirus disease 2019 (COVID-19) pandemic is a major challenge faced by intensive care medicine providers inevitably influencing also CS management. Recent findingsThere is a lack of prospective data as well as international consensus regarding CS classification, patient risk stratification, and MCS use. Veno-arterial extracorporeal membrane oxygenation is considered the first line MCS in refractory CS and Impella the MCS of choice for the left ventricle unloading. Several ongoing randomized trials will provide much-needed evidence for MCS use in the coming years. COVID-19 infection is associated with several cardiovascular disorders complicated by CS and more data regarding the prevalence and mortality of CS during COVID-19 infection are needed.

Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial

“…2,3 Multiple mechanical circulatory support systems have been developed during the past few decades that can be used for hemodynamic stabilization in this patient population. 4 However, currently available mechanical circulatory support (MCS) devices have not been demonstrated to improve survival in cardiogenic shock. 4 Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in patients with severe circulatory collapse.…”

Extracorporeal Membrane Oxygenation During Pregnancy

“…Stasis of blood within the ventricular cavity will increase the risk of thrombosis and eventual catastrophic embolic events. 51 Clinicians caring for patients on VA ECMO should ensure that the left ventricle is able to contract and generate a stroke volume. This may be accomplished by regular surveillance with transthoracic echocardiography and evaluation of the arterial line waveform.…”

“…If the problem persists, unloading of the left ventricle may be accomplished with the placement of a percutaneous left ventricular assist device such as an Impella (drains blood from the left ventricular cavity directly to the aorta, bypassing the aortic valve). 51 Another potentially serious complication of VA ECMO (with peripheral cannulation) is the Harlequin or North-South Syndrome. 52 As explained previously, oxygenated blood returning to the femoral artery from the ECMO circuit will ascend to the chest retrogradely.…”

Transcatheter edge-to-edge repair in patients with mitral regurgitation and cardiogenic shock: a new therapeutic target

“…Cardiogenic shock with concurrent valvular heart disease represents a challenging population with limited therapeutic options. Specifically, moderate-to-severe mitral regurgitation (MR) is present in 5–10% of patients with cardiogenic shock [16,17] – and this population is often at prohibitive-risk for surgical interventions due to their requirement for mechanical ventilation, inotropes, vasopressors, or mechanical circulatory support, representing a cohort without established therapies [9 ▪ ,18,19]. In the SHOCK trial, patients with AMI complicated by cardiogenic shock and severe mitral regurgitation were treated conservatively with an in-hospital mortality of 55% [14].…”