Mechanical circulatory support in the treatment of cardiogenic shock.

Shannon M Fernando, Susanna Price, Rebecca Mathew, Arthur S Slutsky, Alain Combes, Daniel Brodie

Journal: Current opinion in critical care 2022;28(4):434-441

PMID: 35793815

Abstract

PURPOSE OF REVIEW

Cardiogenic shock is a condition that is characterized by end-organ hypoperfusion secondary to reduced cardiac output, and is associated with substantial mortality. The mainstay of therapy for cardiogenic shock is reversal of the underlying cause, and concomitant supportive care with vasoactive medications (vasopressors and inotropes). Patients who continue to deteriorate despite these measures may require mechanical circulatory support (MCS). Here, we review the devices available for MCS, and their associated benefits and risks.

RECENT FINDINGS

Despite growing use worldwide, there is little randomized evidence supporting the routine use of any specific device for MCS in cardiogenic shock. A large randomized trial of the intra-aortic balloon pump did not demonstrate short- or long-term improvement in mortality. The TandemHeart and Impella devices which assist in left ventricular unloading have only been evaluated in small randomized trials, which showed an increase in adverse events without improvement in mortality. Finally, venoarterial extracorporeal membrane oxygenation (provides both circulatory and respiratory support) and is currently being evaluated in large randomized clinical trials.

SUMMARY

Various devices for MCS in cardiogenic shock are available, but routine use is not supported by high-quality randomized evidence. Given the resources required for initiation of MCS, use of these treatments should be limited to centers experienced in advanced cardiac care, and future research should focus on what role (if any) these devices have in clinical practice.

Address: Division of Critical Care, Department of Medicine, University of Ottawa.; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa.; Department of Critical Care, Lakeridge Health Corporation, Oshawa, Ontario, Canada.; Adult Intensive Care Unit, Royal Brompton Hospital.; National Heart and Lung Institute, Imperial College, London, UK.; Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.; Interdepartmental Division of Critical Care Medicine, University of Toronto.; Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.; Sorbonne Université, Institute of Cardiometabolism and Nutrition.; Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Institut de Cardiologie, Paris, France.; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons.; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA.

DOI: 10.1097/MCC.0000000000000956

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MeSH Terms: Extracorporeal Membrane Oxygenation, Heart Ventricles, Heart-Assist Devices, Humans, Intra-Aortic Balloon Pumping, Shock, Cardiogenic, Treatment Outcome