Selection of percutaneous mechanical circulatory support in cardiogenic shock: patient-specific considerations and insights from contemporary clinical data

Abstract

Purpose of review 

Cardiogenic shock remains a complex and variable disease process requiring early recognition and prompt, multidisciplinary treatment. Available data link usage of high-dose and/or multiple vasopressors in cardiogenic shock to increased mortality. This review proposes a structured approach to escalation of percutaneous mechanical circulatory support (pMCS) in cardiogenic shock, based on the hemodynamic and metabolic parameters highlighted in the revised SCAI Shock Classification, and supported by the available clinical data.

Recent findings 

Intra-aortic balloon pumps (IABP) may improve hemodynamics in early cardiogenic shock (stage B) but offer little benefit in stage C–E shock where percutaneous ventricular assist devices (pVAD) improve cardiac power/index and may improve survival in certain subsets. In stage D–E shock, escalation from standalone pVADs to devices in combination is often appropriate. Left ventricular venting, with IABP or Impella, in conjunction with VA ECMO, appears to be beneficial.

Summary 

Graded escalation of pMCS support should be considered in SCAI stage B shock patients onwards, with the choice of support allowable by local expertise, matched to the degree and anticipated trajectory of hemodynamic and metabolic compromise. Additional clinical data are required before timing, and escalation of pMCS initiation may be integrated into a single treatment algorithm.