Expert Consensus Statement on Percutaneous Mechanical Circulatory Support Devices | Ten Points to Remember
- Rihal CS, Naidu SS, Givertz MM, et al.
- 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. J Am Coll Cardiol 2015;Apr 7:[Epub ahead of print].
The following are 10 points to remember about this clinical expert consensus statement on the use of percutaneous mechanical circulatory support (MCS) devices in cardiovascular care:
- Although historically the intra-aortic balloon pump (IABP) has been the only MCS device available to clinicians, a number of new devices have become commercially available. Percutaneous MCS devices provide superior hemodynamic support compared to pharmacologic therapy. This is particularly apparent for the Impella and TandemHeart devices.
- Patients in cardiogenic shock represent an extremely high-risk group in whom mortality has remained high despite revascularization and pharmacologic therapies. Early placement of an appropriate MCS device may be considered in those who fail to stabilize with initial therapies.
- MCS devices may be considered for patients undergoing high-risk percutaneous coronary intervention (PCI), such as those requiring multivessel, left main, or last patent conduit interventions, particularly if the patient is inoperable or has severely decreased ejection fraction or elevated cardiac-filling pressures.
- In the setting of profound cardiogenic shock, IABP is less likely to provide benefit than continuous flow pumps including the Impella CP and TandemHeart. The extracorporeal bypass with membrane oxygenator (ECMO) may also provide benefit, particularly for patients with impaired respiratory gas exchange.
- Patients with acute decompensated heart failure may benefit from early use of percutaneous MCS devices when they continue to deteriorate despite initial interventions. MCS devices may be considered if patients are candidates for surgically implanted ventricular assist devices (VADs) or if rapid recovery is expected (e.g., fulminant myocarditis or stress-induced cardiomyopathy).
- There are at present insufficient data to support or refute the notion that routine use of MCS devices as an adjunct to primary revascularization in the setting of large acute myocardial infarction are useful in reducing reperfusion injury or infarct size.
- MCS devices may be used for failure to wean off cardiopulmonary bypass, considered as an adjunct to high-risk electrophysiologic procedures when prolonged hypotension is anticipated or, rarely, for valvular interventions.
- Severe biventricular failure may require use of both right- and left-sided percutaneous MCS or venoarterial ECMO. Certain patients may respond to left ventricular assist device (LVAD) implantation with inotropes and/or pulmonary vasodilators to support the right heart. MCS devices may also be considered for isolated acute right ventricular failure complicated by cardiogenic shock.
- Registries and randomized controlled trials comparing different strategies in different clinical scenarios are urgently needed to assess true efficacy and safety of these devices.
- Early analyses suggest cost-effectiveness of MCS for emergent use in comparison to surgical ECMO or VAD support, and for elective use in comparison to IABP; however, additional prospective data are needed.
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