Top Things to Know: Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock

Published: July 07, 2022

Prepared by Mark N. Belkin, MD, University of Chicago Cardiovascular Diseases Advanced Heart Failure & Transplant Cardiology Fellow, PGY-7

  1. This scientific statement provides guidance to inform clinical decision-making with respect to escalation and de-escalation of temporary mechanical circulatory support (tMCS) devices in cardiogenic shock, including left-, right-, or bi-ventricular support when used as a bridge-to -decision, -recovery, or -destination therapy (i.e., durable left ventricular assist device or heart transplant).
  2. Continuous pulmonary artery catheter (PAC) monitoring can help identify the need for tMCS therapy and to match the appropriate device selection to the right patient at the right time. PACs can also help in the comprehensive serial clinical assessment needed for escalation, maintenance, and de-escalation of tMCS.
  3. An interdisciplinary “Shock Team” which may include a cardiac intensivist, advanced HF and transplantation cardiologist, interventional cardiologist, clinical cardiologist, cardiac surgeon, ECMO specialist, palliative care specialist, nursing specialist, and relevant consultants, plays an important role in decisions regarding escalation of tMCS in patients with clinical evidence of hypoperfusion and/or hemodynamic deterioration despite initial vasoactive or tMCS support.
  4. In patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS), tMCS can be considered pre- or post- percutaneous coronary intervention (PCI) depending on shock severity and phenotype. Intra-aortic balloon pump (IABP) may not provide adequate support in patients with significant AMI-CS from left ventricular (LV) dysfunction, in which case a percutaneous left ventricular support device (e.g., Impella CP) may be an option pre- or post-PCI.
  5. The risk of right ventricular (RV) failure can be reduced by close monitoring and rapid treatment of reversible causes (i.e., acidosis, hypoxia, progressive left ventricular dysfunction). Progressive RV shock can be mitigated by prompt diagnosis and initiation of RV-specific tMCS devices (e.g., Impella RP, right-sided TandemHeart, ProtekDuo, surgical temporary RVAD) or escalation to biventricular support (e.g., percutaneous or surgical VA-ECMO, or TandemHeart) when appropriate.
  6. In patients with isolated left- or right- ventricular failure it’s important to serially monitor for progression to biventricular failure with need for escalation to biventricular support.
  7. Patients with heart failure complicated by cardiogenic shock (HF-CS) can benefit from afterload reduction if mean arterial pressure is greater than 65 mmHg, along with diuretic strategies to alleviate congestion. For those patients in refractory shock despite inotropes and diuretics, prompt escalation to tMCS may be necessary.
  8. Echocardiography used in the intensive care setting can help assess for adequate LV unloading (in the case of VA-ECMO support), evaluate device positioning (in the case of Impella devices), and monitor for potential complications. Complications associated with tMCS include vascular, neurologic, hematologic, mechanical, or infectious.
  9. Daily assessment for device de-escalation is important in conjunction with an interdisciplinary team using a combination of invasive hemodynamics, echocardiography, laboratory tests, and clinical examination. Indicators for successful de-escalation include euvolemia, hemodynamic stability, minimal vasoactive support with evidence of improvement or resolution of the underlying etiology of their cardiogenic shock.
  10. Weaning of tMCS is best achieved in a device-specific, stepwise fashion. Since longer duration of tMCS use is associated with worse outcomes, the goal of weaning is explanting the devices as soon as it is safe, which may be facilitated by utilization of low-dose vasoactive medications. tMCS weaning in AMI-CS patients can often be done more expeditiously, compared to HF-CS, perhaps due to likelihood of recovery after revascularization of an acute ischemic insult.
  11. Early, simultaneous evaluation for advanced therapies (namely, durable left ventricular assist device or heart transplant) and consultation with advanced heart failure and transplant cardiologists is important in patients managed with tMCS in case myocardial recovery and device weaning is unsuccessful.
  12. Palliative care experts play an important role in escalation and de-escalation of tMCS to help support the patient, family, and inter-disciplinary team through recovery, bridge to definitive support, and cases of withdrawal of life-sustaining therapy.

View the summary for Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock

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Citation

Geller BJ, Sinha SS, Kapur NK, Bakitas M, Balsam LB, Chikwe J, Klein DG, Kochar A, Masri SC, Sims DB, Wong GC, Katz JN, van Diepen S; on behalf of the American Heart Association Acute Cardiac Care and General Cardiology Committee of the Council on Clinical Cardiology; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; and Council on Cardiovascular Surgery and Anesthesia. Escalating and de-escalating temporary mechanical circulatory support in cardiogenic shock: a scientific statement from the American Heart Association [published online ahead of print July 7, 2022]. Circulation. doi: 10.1161/CIR.0000000000001076

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