Mechanical Circulatory Support: When and How to Use It

Purpose of review The goal of this review is to provide the reader with a summary of the percutaneous mechanical circulatory support (MCS) devices currently used in clinical practice. Recent findings Although there are limited data for MCS including intra-aortic balloon pump (IABP), percutaneous left ventricular (LV) micro-axial pump (Impella), percutaneous left ventricular (LV) centrifugal pump (TandemHeart), VA-extracorporeal membrane oxygenation (VA-ECMO), and right ventricular (RV) support (Impella RP, Protek Duo), these devices are frequently employed in clinical practice. Summary Guidelines largely support the use of MCS in refractory ischemic and non-ischemic cardiogenic shock (CS). However, the literature to support MCS use is limited, especially in the setting of high-risk PCI. Ongoing randomized clinical trials of these devices will help to provide supportive data for MCS utilization in various clinical settings. Opinion statement Percutaneous mechanical circulatory support (MCS) has become an important adjunctive therapy in clinical practice for a variety of indications, including cardiogenic shock secondary to acute myocardial infarction (AMI-CS), cardiogenic shock secondary to acute decompensated heart failure (ADHF-CS), a bridge to advanced therapies, left ventricular (LV) unloading, high-risk PCI, and extracorporeal cardiopulmonary resuscitation (eCPR). Although there is a lack of robust data for many of these devices, MCS is recommended in an algorithmic approach in the modern era. Intra-aortic balloon pump (IABP) use is mostly limited to patients with mechanical complications of AMI, persistent ischemia in the setting of un-revascularized disease, early CS or as a bridge to durable support in non-AMI CS, or in refractory CS if other MCS devices are contraindicated. IABP support is often escalated to Impella or VA-extracorporeal membrane oxygenation (VA-ECMO) in advanced stages of CS. In cases of prolonged support as a bridge to durable treatment, Impella 5.0 or 5.5 should be considered. For high-risk PCI, Impella CP is frequently used as supportive therapy although more data are needed to clearly define its role for this indication. Impella RP and Protek Duo are commonly used devices to support the right ventricle (RV). VA-ECMO is frequently used for severe biventricular shock, but “Bi-Pella” (Impella CP/5.0/5.5 + Impella RP) remains an option when VA-ECMO is not feasible. Future randomized data will help to delineate the role for MCS devi