Short-term percutaneous mechanical circulatory support: no promise without positioning

Short-term percutaneous mechanical circulatory support by a micro-axial flow pump is increasingly used to support the left ventricle in cardiogenic shock. After a correct indication and placement, appropriate device management in the cardiac intensive care unit is vital to ensure optimal pump function and adequate haemodynamic support. A key element hereby is a correct percutaneous ventricular assist device (pVAD) position. This review explains how an optimal left-sided pVAD position can be achieved and maintained, focusing on the correct insertion depth and rotational angle. Useful imaging techniques, placement and replacement manoeuvres, and monitoring options through the console are discussed. The frequently encountered problem of mal-rotation towards the mitral valve, which may cause suction alarms, haemolysis, aortic regurgitation, and inadequate haemodynamic support, is explained. Finally, a practical bedside approach to assess pVAD position and discern suction alarms due to mal-positioning from haemodynamic problems is proposed.