Percutaneous Circulatory Support in Cardiogenic Shock

Abstract

Over the past 2 decades, innovation in the realm of mechanical ventricular assist devices (VADs) has altered the management of cardiogenic shock (CS). Percutaneous VADs (PVADs) allow emergent and effective ventricular unloading while providing sufficient systemic perfusion pressure to reverse end-organ dysfunction. Despite relatively few randomized trials evaluating these devices, some cardiovascular society guidelines recommend the use of PVADs in patients not responding to standard treatments for CS, including intra-aortic balloon pump (IABP) counterpulsation (Class IIa, Level of Evidence C).1 The purpose of this review is to highlight the spectrum of CS, to review modern PVADs as an interventional bridge to recovery, to discuss unique clinical issues related to PVAD support, and finally to offer a perspective on the future directions of acute mechanical circulatory support research. CS is a state of end-organ hypoperfusion caused by left ventricular (LV), right ventricular (RV), or biventricular myocardial injury resulting in systolic and/or diastolic myocardial pump failure. Myocardial infarction (MI) with LV failure remains the most common cause of CS. In general, CS complicates 8.6% of ST-segment elevation MIs (STEMI)2 and 2.5% of non–ST segment elevation MIs.3 Common causes of CS are listed in Table 1. View this table: Table 1. Common Causes of Cardiogenic Shock Clinically, CS is defined by both hemodynamic parameters (persistent hypotension [systolic blood pressure 18 mm Hg or RV end-diastolic pressure >10–15 mm Hg]) and clinical signs/symptoms of hypoperfusion (cool extremities, decreased urine output, and/or altered mental status). Inadequate systemic perfusion results in secondary lactic acidosis, catecholamine and neurohormone release, and activation of …