The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges

ABSTRACT

Introduction: Cardiogenic shock due to acute myocardial infarction and decompensated advanced heart failure remains a source of significant morbidity and mortality. Endovascular mechanical circulatory support devices including intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (Impella and Tandemheart pumps), and veno-arterial extracorporeal oxygenation (VA-ECMO) are utilized for a broadening range of indications.

Areas covered: This narrative review explores the specific devices, their distinctive hemodynamic profiles, and practical considerations. Furthermore, reviewed are the trials evaluating device outcomes which have generated significant controversy within the field of heart failure and shock. New applications and future directions are discussed.

Expert opinion: Use of endovascular mechanical circulatory support has increased over the last decade, though evidence supporting their use is lacking. Development of large-scale prospective registries and clinical classification systems will facilitate patient enrollment and inform trial design. Furthermore, expansion of indications for these devices is revolutionizing how the field of heart failure and cardiogenic shock thinks about hemodynamic support. The ability to tailor therapy to a patient’s specific hemodynamic profile appears to be the future of cardiogenic shock management.

KEYWORDS:

• Acute myocardial infarction
• cardiogenic shock
• heart failure
• Impella
• intra-aortic balloon pump
• mechanical circulatory support
• percutaneous left ventricular assist device
• TandemHeart
• veno-arterial extracorporeal membrane oxygenation
• Va-ECMO

Article highlights

• Each percutaneous mechanical circulatory support device has a unique hemodynamic profile.

• Utilization of endovascular mechanical circulatory support devices is on the rise, though evidence for their use is limited.

• There is growing evidence to support diversification of device indications.

• Development of large-scale prospective registries and clinical classifications systems may aid in hypothesis generation and inform randomized trial design.

Declaration of interest

N Kapur receives consulting/speaker honoraria and institutional grant support from: Abbott Laboratories, Abiomed Inc., Boston Scientific, Medtronic, LivaNova, MDStart, and Precardia. None of the other authors has any relevant affiliations or financial involvement.

Reviewer disclosures

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

Additional information

Funding

This paper was not funded.