Abstract
Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use. Multiple devices exist across a spectrum from modest to complete support, and each is associated with unique risks. In this review, we summarize existing data on complications associated with the three most widely used acute MCS platforms: the intra-aortic balloon pump (IABP), Impella systems, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We review evidence from available randomized trials and highlight challenges comparing complication rates from case series and comparative observational studies where a lack of granular data precludes appropriate matching of patients by CS severity. We further offer a series of best practices to help shock practitioners minimize the risk of MCS-associated complications and ensure the best possible outcomes for patients.
Highlights
Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use
Acute mechanical circulatory support in cardiogenic shock Cardiogenic shock (CS) is an advanced state of hemodynamic compromise representing a convergent endpoint of cardiac decompensation resulting from acute myocardial infarction, end-stage heart failure, myocarditis, and various other conditions
Limb ischemia among acute myocardial infarction complicated by CS (AMICS) patients treated with intra-aortic balloon pump (IABP), percutaneous VADs (Impella or TandemHeart), or veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are exemplary of these trends
Summary
Faculty Reviews are review articles written by the prestigious Members of Faculty Opinions. Two small randomized trials comparing the TandemHeart device to IABP showed a clear signal toward higher rates of bleeding and limb ischemia with TandemHeart, though these trends were significant in only one of the two studies[16,17]. The IMPELLA-STIC trial compared IABP alone to IABP plus Impella 5.0 in 12 patients with AMICS and found a significantly higher rate of major bleeding in the combined device group, though the study was too small to evaluate the significance of other complication trends[20]. Only one randomized trial has evaluated the use of VA-ECMO in CS: the Extracorporeal Life Support in cardiogenic Shock complicating acute myocardial infarction (ECLS-SHOCK) trial randomized 42 post-arrest AMICS patients to VA-ECMO or no MCS and found similar rates of complications between groups, though again the study
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