Mechanical Support Devices in Cardiogenic Shock

Thiele H, Jobs A, Ouweneel DM, et al.
Percutaneous Short-Term Active Mechanical Support Devices in Cardiogenic Shock: A Systematic Review and Collaborative Meta-Analysis of Randomized Trials. Eur Heart J 2017;Jul 7:[Epub ahead of print].

The following are key points to remember from this review on percutaneous short-term active mechanical circulatory support (MCS) devices in patients with cardiogenic shock (CS):

  1. Evidence on the impact on clinical outcome of active MCS devices in CS is scarce.
  2. Mortality of CS complicating acute myocardial infarction (AMI) remains high despite modern treatment strategies including early revascularization and best available medical therapy.
  3. The hemodynamic benefits of inotropes and vasopressors appear to be counterbalanced by adverse effects such as increased myocardial oxygen demand, arrhythmogenicity, and compromise of tissue microcirculation, which may translate into an increased mortality risk.
  4. The use of active MCS appears to be a promising therapeutic concept to improve cardiac output while avoiding the possible cardiotoxicity of catecholamines.
  5. Several controlled trials comparing the efficacy and safety of active percutaneous MCS versus control in CS complicating AMI have been performed.
  6. The individual trials were underpowered to adequately evaluate a potential mortality benefit.
  7. A collaborative meta-analysis of four randomized trials investigating the efficacy and safety of percutaneous active MCS versus control with intra-aortic balloon pump demonstrates similar short-term mortality despite initial beneficial effects on mean arterial pressure (MAP) and reduction of arterial lactate.
  8. Despite an initial beneficial effect on MAP and arterial lactate, active percutaneous MCS did not improve mortality in comparison to control in patients with CS complicating AMI, which may be partly explained by an excess of complications such as bleeding.
  9. According to current guidelines, MCS should be considered primarily in patients with refractory CS.
  10. Based on contemporary evidence, it appears prudent to restrict the use of active percutaneous MCS to selected patients.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardio-Oncology, Heart Failure and Cardiomyopathies, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support

Keywords: Arterial Pressure, Acute Coronary Syndrome, Cardiac Output, Cardiotoxicity, Catecholamines, Heart-Assist Devices, Heart Failure, Hemodynamics, Hemorrhage, Intra-Aortic Balloon Pumping, Microcirculation, Myocardial Infarction, Shock, Cardiogenic

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