5 - Acute Circulatory Support

Abstract

Cardiogenic shock (CS) is an urgent state of cardiac insufficiency associated with high morbidity and mortality that can complicate many cardiac conditions. Timely diagnosis and rapid intervention are required to restore cardiac output and end-organ perfusion before irreversible multisystem dysfunction and activation of the systemic inflammatory response ensue. Data suggest that outcomes for patients with CS may be improved with rapid institution of temporary mechanical circulatory support (TCS) compared with isolated chemical support in the form of vasopressors and/or inotropes. TCS can be used in those with refractory shock as a bridge to durable ventricular assist device (VAD) support, providing clinicians with the critical time needed for advanced heart failure evaluation and shared decision-making to avoid futile or unwanted durable VAD interventions. While VAD operative morbidity and mortality are higher in durable VAD patients requiring TCS compared with that of less ill VAD patients, outcomes in carefully selected VAD candidates with CS are superior to medical management alone. In this chapter, the TCS devices presently available for management of CS, the clinical data and complication profiles of TCS, as well as important considerations during the transition from TCS to durable mechanical circulatory support are reviewed.