Short-term mechanical circulatory support by veno-arterial extracorporeal membrane oxygenation in the management of cardiogenic shock and end-stage heart failure

Abstract

Despite modern treatment modalities, cardiogenic shock is associated with a very high risk of mortality and morbidity. The short- and long-term survival in patients with cardiogenic shock or end-stage heart failure has improved considerably by recent technological advances in short and long-term mechanical circulatory support devices. For short-term mechanical support, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used as bridge-to-decision and bridge-to-recovery in cardiogenic shock patients. Long-term mechanical circulatory support devices such as left ventricular assist devices (LVADs) are widely available and play a central role in bridge-to-transplantation in those eligible for heart transplantation (HTX) and as destination therapy (DT) in those not eligible for heart transplantation. Nevertheless, patients with critical cardiogenic shock show a deleterious outcome after LVAD-implantation or HTX with higher mortality, more complications and higher burden on financial resources. These considerations underscore the importance of optimal timing and appropriate patient selection for eventual LVAD therapy. The current report will focus on the immediate management of patients with cardiogenic shock with inotropes, discuss the use of IABP and focus mainly on pivotal choices to be made in the period spanned by short term mechanical circulatory support in patients with refractory cardiogenic shock.

Keywords::

• assist device
• cardiogenic shock
• ECMO
• heart failure
• LVAD
• mechanical circulatory support

Financial & competing interests disclosure

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Refractory cardiogenic shock is associated with high mortality rates.

• Short-term mechanical support devices like veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been shown to improve patient outcome in cardiogenic shock complicating acute myocardial infarction, cardiac arrest and fulminant myocarditis.

• VA-ECMO provides a rapid and full circulatory support and to reverse severe hypoperfusion organ injury if initiated early, providing additional time to make a right long-term decision.

• VA-ECMO is relatively easy to implant percutaneously at patient's bedside in 15 min.

• VA-ECMO can be used as bridge-to-recovery, but in most it will be used as bridge-to-bridge (left ventricular assist device) or bridge-to-urgent heart transplantation.

• Proper selection and timing of the patients eligible for long-term mechanical circulatory support devices is essential as a conservative approach is justified considering the deleterious outcomes in the INTERMACS profile 1.

Notes

Data taken from [1].