Mechanical circulatory support in cardiogenic shock: a critical appraisal

ABSTRACT

Introduction

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encounter in patients with multivessel coronary artery disease (MVD).

Areas covered

Despite prompt revascularization, in particular percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for CS related to AMI remains high. Differently from hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested in AMI-CS patients, based on the results of a recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have raised as a key therapeutic option in CS, especially in case of an early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of current evidences on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of MCS devices, and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

Expert opinion

Emerging observational experience suggested that an early implantation of MCS (prior to PCI), the performance of an extensive revascularization and the implementation of shock teams and networks are key factors for improving clinical outcomes.

KEYWORDS:

• Cardiogenic shock
• acute myocardial infarction
• mechanical circulatory support
• left ventricular assist devices

Article highlights

• Despite conflicting evidence, temporary MCS are being used with increasing frequency to manage patients in CS.

• The assessment of patients’ characteristics as the acuity of illness, the CS phenotype and the vascular access anatomy are essential steps in choosing the type of device required.

• A timely MCS implantation, escalation and weaning should be based on a multiparametric evaluation.

• The role of a multidisciplinary team and standardized protocol in dedicated shock center remain pivotal.

• Randomized trials and larger registries are needed to guide optimum management of MCS selection for CS.

Declaration of Interest

G Tarantini reports receiving speakers fees from Abiomed and GADA. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.