Cardiogenic Shock: Mechanical Circulatory Support; Rise of the Machines

Let me start off by saying that not every patient who is hypotensive is septic, contrary to what every medicine resident thinks. I could say that because I was a medicine resident at one point. There are 3 other types of shock that are not distributive. We are here to talk about the Cardiogenic kind of shock and the Mechanical Circulatory Devices we can use to save the lives of these patients. The last time this page was updated was 10.17.22.

If this page helped you out on your own presentation, please cite it as:
Eddy J. Gutierrez, “Cardiogenic Shock: Mechanical Circulatory Support Devices – Rise of the Machines”, eddyjoemd blog, October 17, 2022. Available at: http://eddyjoemd.com/cardiogenic-shock-mcs.

Thanks! Please reach out to me at eddyjoemd@gmail.com if you would like to book me to present this lecture on Cardiogenic Shock at your institution either live or via webinar.

Cardiogenic Shock: Definition

Cardiogenic Shock is defined as shock that is due to ineffective cardiac output due to a primary cardiac dysfunction. Obviously the shock part of this is that that leads to inadequate organ perfusion. This leads inflammation, vasoplegia, a decrease in coronary flow, and then game over.

Etiology:
The most common cause of cardiogenic shock is acute myocardial infarctions, but acute on chronic heart failure is also commonly seen. The interventional cardiologist, if applicable goes ahead and fixes the lesion and may/may not place a device for mechanical circulatory support. What is our job as the critical care team? To find a way increase the organ perfusion of these patients. Vasopressors and inotropes are nice, readily available, but sometimes these patients need more help. I have also discussed in the past how, despite epinephrine seeming to be the more favorable in cardiogenic shock compared to norepinephrine, norepinephrine may end up being the better vasopressor for these patients. Please don’t bombard these patients with fluids.

SCAI Definitions

Baran DA, Grines CL, Bailey S, Burkhoff D, Hall SA, Henry TD, Hollenberg SM, Kapur NK, O’Neill W, Ornato JP, Stelling K, Thiele H, van Diepen S, Naidu SS. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv. 2019 Jul 1;94(1):29-37. doi: 10.1002/ccd.28329. Epub 2019 May 19. PMID: 31104355.
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Phenotypes of Cardiogenic Shock

Zweck E, Thayer KL, Helgestad OKL, Kanwar M, Ayouty M, Garan AR, Hernandez-Montfort J, Mahr C, Wencker D, Sinha SS, Vorovich E, Abraham J, O’Neill W, Li S, Hickey GW, Josiassen J, Hassager C, Jensen LO, Holmvang L, Schmidt H, Ravn HB, Møller JE, Burkhoff D, Kapur NK. Phenotyping Cardiogenic Shock. J Am Heart Assoc. 2021 Jul 20;10(14):e020085. doi: 10.1161/JAHA.120.020085. Epub 2021 Jul 6. PMID: 34227396; PMCID: PMC8483502.
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Why do we need Cardiogenic Shock Teams?

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The team consists of an Intensivist (they say critical care cardiology but I’ve met only one of these guys), advanced heart failure, interventional cardiology, cardiac surgery, and the ECMO service (if available).
These patients get taken care of better. Let’s just make it clear:
– fewer end up on the vent (NNT 8.8)
– fewer require dialysis (NNT 12.2)
– they spend less time in the ICU
– their mortality is lower (The team consists of an Intensivist (they say critical care cardiology but I’ve met only one of these guys), advanced heart failure, interventional cardiology, cardiac surgery, and the ECMO service (if available).
These patients get taken care of better. Let’s just make it clear:
– fewer end up on the vent (NNT 8.8)
– fewer require dialysis (NNT 12.2)
– they spend less time in the ICU
– their mortality is lower
– they’re less likely to require mechanical circulatory support
– they’re less likely to have a balloon pump placed and more likely to have an Impella placed.
– when taking a closer look at the mortality data, the NNT is 16.7. Wish it was lower but that’s definitely a benefit just from having a team in place.)
– they’re less likely to require mechanical circulatory support
– they’re less likely to have a balloon pump placed and more likely to have an Impella placed.

Papolos AI, Kenigsberg BB, Berg DD, Alviar CL, Bohula E, Burke JA, Carnicelli AP, Chaudhry SP, Drakos S, Gerber DA, Guo J, Horowitz JM, Katz JN, Keeley EC, Metkus TS, Nativi-Nicolau J, Snell JR, Sinha SS, Tymchak WJ, Van Diepen S, Morrow DA, Barnett CF; Critical Care Cardiology Trials Network Investigators. Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams. J Am Coll Cardiol. 2021 Sep 28;78(13):1309-1317. doi: 10.1016/j.jacc.2021.07.044. PMID: 34556316.
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Where do these people go when they get sick? Did you know that one of my colleagues and his team looked at the AMI-CS registry and found that 90% of these patients are treated at non-academic institutions? Thank includes community hospitals such as where I practice and private hospitals. That means that only 10% go to the academic institutions or government hospitals.

Wayangankar SA, Bangalore S, McCoy LA, Jneid H, Latif F, Karrowni W, Charitakis K, Feldman DN, Dakik HA, Mauri L, Peterson ED, Messenger J, Roe M, Mukherjee D, Klein A. Temporal Trends and Outcomes of Patients Undergoing Percutaneous Coronary Interventions for Cardiogenic Shock in the Setting of Acute Myocardial Infarction: A Report From the CathPCI Registry. JACC Cardiovasc Interv. 2016 Feb 22;9(4):341-351. doi: 10.1016/j.jcin.2015.10.039. Epub 2016 Jan 20. PMID: 26803418.
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Do we Need PA Catheters?

I have a more thorough post on this topic HERE.

Garan AR, Kanwar M, Thayer KL, Whitehead E, Zweck E, Hernandez-Montfort J, Mahr C, Haywood JL, Harwani NM, Wencker D, Sinha SS, Vorovich E, Abraham J, O’Neill W, Burkhoff D, Kapur NK. Complete Hemodynamic Profiling With Pulmonary Artery Catheters in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. JACC Heart Fail. 2020 Nov;8(11):903-913. doi: 10.1016/j.jchf.2020.08.012. PMID: 33121702.
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Sotomi Y, Sato N, Kajimoto K, Sakata Y, Mizuno M, Minami Y, Fujii K, Takano T; investigators of the Acute Decompensated Heart Failure Syndromes (ATTEND) Registry. Impact of pulmonary artery catheter on outcome in patients with acute heart failure syndromes with hypotension or receiving inotropes: from the ATTEND Registry. Int J Cardiol. 2014 Mar 1;172(1):165-72. doi: 10.1016/j.ijcard.2013.12.174. Epub 2014 Jan 9. PMID: 24447746.
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Cardiac Power Output

What is a good hemodynamic correlate for whether a patient is going to do well when they’re in Cardiogenic Shock? In our guts we want to look at the usual suspects for hemodynamic monitoring: mean arterial pressure, heart rate, etc. Heck, we may even get a bit fancy, float a pulmonary artery catheter, and get wedge pressure, stroke volume, cardiac index, etc. Bottom line is that looking at the blood pressure isn’t going to cut it. Data published in 2004 suggests that looking at the cardiac power output (CPO) is the way to go. Per the data found by Fincke et al. looking at patients enrolled in the shock trial, they found that Cardiac Power was the “strongest independent hemodynamic correlates of in-hospital mortality”. I know that many people use mean arterial pressure as the end-all be-all for hemodynamics but those people are playing in the little leagues. The good news is that it doesn’t take much to be promoted to the big leagues! The reason why I emphasize that is because we need to take a deeper give into the mean arterial pressure equation.

MAP=(CO x SVR)

I have said this on numerous different posts but our management of these patients depends on our ability to sort out the cardiac output (by altering the heart rate, adjusting the stroke volume, adding inotropes, or in the case of this post adding mechanical circulatory support) of these patients and use our vasopressors to tweak the systemic vascular resistance. Some texts add the CVP but whether or not that is added is beyond the scope of this post. To reiterate, looking at just the MAP fails to pick out whether the issue is the CO or the SVR. I have seen clinicians increase the pressors into oblivion creating too much afterload for the failing heart to even know what to do with. Add another plate to the bench press of a struggling amateur lifter. Yeah, this makes the MAP look pretty, until the heart can’t lift the bar off of its chest. Okay, enough with the gym references.

How do you calculate cardiac power output? So glad you asked.

CPO=(MAP X CO)/451

Again, we’re playing in the big leagues here. You’re going to need to measure cardiac output or cardiac index to correctly care for these patients. A recently published study shows that the NICOM devices are not as good as a swan-ganz catheter to do these calculations that I have covered in the past. But I figure it’s better than going in completely blind and trying to manage the patient based on a mean arterial pressure. Also, there’s now data for all the PA catheter naysayers that “Complete Hemodynamic Profiling With Pulmonary Artery Catheters in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality“. Unfortunately, that article isn’t free but I digress. I also hope that if you’re caring for a patient who is in cardiogenic shock that they have a reliable arterial line in place. The Zentensivist part of me obviously likes to avoid unnecessary procedures but, as I will reiterate numerous times during this post, the mortality rate for cardiogenic shock is around 50% so there’s no time to be messing around. Especially when delaying care skyrockets the mortality numbers.

The CPO we should shoot for is >0.6. A cardiac power power < 0.6 is a poor prognostic indicator. So you have your swan in place, you’re getting your numbers but management isn’t quite cutting it. The CPO isn’t happy, your patient isn’t doing well. Time to step up your game. How you say? Time to call up your friendly neighborhood interventional cardiologist to place some sort of mechanical circulatory support device. If your interventional cardiologist cannot do it, it is time to call a neighboring facility. Ego does not save lives. Transferring patients to places where they can get the help they need does. You also should calculate a PAPi score to see if right sided assistance is in the cards for the patient. I will get into the PAPi score a little later in this post.

For now, just be aware that the more recent studies that have shown an improvement from the default 50% mortality in cardiogenic shock that we have all gotten used to have used the Cardiac Power Output as a marker for overall and primarily left ventricular function. The way I use cardiac power output in my practice is quite simple. This is not medical advice. This is an example of how I triage my personal energy. I use a cardiac index of 2.2 as my worry cutoff. Although the normal range for cardiac index is 2.5-4L/min/m², one has to remember that these are not normal patients. After all, they are in cardiogenic shock. Once I see what their index and cardiac output is (one can get the cardiac output on the screen as well) I check to see how much support they are receiving from the vasopressors and inotropes. At the same time I looked at the CI/CO I also glanced at the SVR. The SVR can be calculated by the following equation:

SVR = (MAP – CVP)/CO

If the SVR is too high, i.e. greater than 1200, I ask the nurses to come down on the vasopressors. You may be providing the patient with too much afterload. If the patient was receiving too much afterload, you will see the cardiac index/output improve. This is when you want to go ahead and calculate your CPO. You don’t want to pull the trigger prematurely and calculate a CPO that was falsely low because your vasopressors were inappropriate. Remember, we don’t want to do any procedures to any patients unless we absolutely have to. Then I ask the nursing staff if they have been going up or coming down on the vasopressors and/or inotropes. If the patient has been getting sicker and the CPO < 0.6, I make the call. Heck, even if the patient has been trending in the wrong direction, I make a “heads up call”. After all, our interventional cardiology friends need to call in the cath lab squad and that’s a significant amount of resources. Remember, making the call to transition to mechanical circulatory support changes the dynamics with regards to cost of device but also the significant amount of people needed to care for these patients. My point for all this is that these patients need a significant amount of brainpower and attention to detail to save their lives. Getting over the 50% mortality hump needs a very good multidisciplinary team to sort them out.

Cardiogenic Shock with Multiple Organ Failure Leads to Higher Mortality

Vallabhajosyula S, Dunlay SM, Prasad A, Kashani K, Sakhuja A, Gersh BJ, Jaffe AS, Holmes DR Jr, Barsness GW. Acute Noncardiac Organ Failure in Acute Myocardial Infarction With Cardiogenic Shock. J Am Coll Cardiol. 2019 Apr 16;73(14):1781-1791. doi: 10.1016/j.jacc.2019.01.053. PMID: 30975295.
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Are Shock Teams Beneficial?

Mechanical Circulatory Support Devices

There are a several devices to choose from depending on the level of support that your patient needs. If you and your team are not familiar with these devices and their management, it may be prudent to transfer these patients EARLY to a facility that is comfortable with these processes. The cited paper below had a great table outlining the different assist devices available ranging from the intraaortic balloon pump all the way up to VA-ECMO. For the sake of time, I will defer the nuances of each device also to this article.

Devices discussed in this article include:
– Intraaortic Balloon Pump (IABP)
– TandemHeart
– Impella 2.5, CP, 5.0
– VA-ECMO (veno-arterial extracorporeal membranous oxygenation)
– ECPella

I am aware that there are other devices out there, but for the sake of what you can find in the article linked, this is what they mainly discuss. When it comes to choosing what to focus on for a lecture or a broad post such as this one, it’s helpful to know what people are actually doing in the real world outside of ones own institution. There was a survey published in the Journal of Invasive Cardiology in 2020 by Dr. Angie Lobo who went to the same medical school as me, where they asked a number of clinicians which mechanical circulatory support devices are offered at their institution amongst other questions. They found that 92.42% had IABP’s, 78.2% had Impella’s, 65.88% had VA-ECMO, and 28.44% had TandemHearts. When it comes down to patients who have both acute myocardial infarction AND cardiogenic shock, the most commonly used devices are the Impella (48.34%), the IABP (43.6%), followed by VA-ECMO (7.58%). The TandemHeart got a zero percent here.

Intraaortic Balloon Pump

Should we still be using balloon pumps? (Article shared on on 10/6/21)

Heringlake M, Berggreen AE, Paarmann H. Still a place for aortic counterpulsation in cardiac surgery and patients with cardiogenic shock? Crit Care. 2021 Aug 31;25(1):309. doi: 10.1186/s13054-021-03673-8. PMID: 34461956; PMCID: PMC8407061.
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Impella

I am going to tackle Impella before TandemHeart not because of a conflict of interest, but rather because recently, there was a systematic review and meta-analysis regarding the use of Impella in cardiogenic shock following acute myocardial infarction that unfortunately is not free.

Impella in Myocarditis (Updated on 05.05.22)

Hori T, Iida M, Uchiyama M, Shimokawa T. Successful cases of percutaneous left ventricular assist device “Impella” to fulminant myocarditis. J Cardiothorac Surg. 2022 Apr 12;17(1):72. doi: 10.1186/s13019-022-01821-x. PMID: 35414115; PMCID: PMC9004069.
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Impella Complications

The work by Vargas et al. showed the following complication rates. One needs to take into account that, compared to the IABP, the Impella device is something that interventional cardiologists are still learning. As with anything else, complication rates should decrease with experience and some studies have reflected that. In the systematic review and meta-analysis that included studies from 2005 to 2019, they found major bleeding in 19.9%, hemolysis in 10.5%, limb ischemia in 5.0%, and stroke in 3.8% of patients. These data are good to have accessible so one could explain to family members that these devices, as life saving as they may be, are not without risks.

Biventricular Impella Support

Kuchibhotla S, Esposito ML, Breton C, Pedicini R, Mullin A, O’Kelly R, Anderson M, Morris DL, Batsides G, Ramzy D, Grise M, Pham DT, Kapur NK. Acute Biventricular Mechanical Circulatory Support for Cardiogenic Shock. J Am Heart Assoc. 2017 Oct 20;6(10):e006670. doi: 10.1161/JAHA.117.006670. PMID: 29054842; PMCID: PMC5721869.
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TandemHeart

VA-ECMO

ARTICLE SHARED ON SOCIAL MEDIA on 10/6/22

Rajsic S, Treml B, Jadzic D, Breitkopf R, Oberleitner C, Popovic Krneta M, Bukumiric Z. Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications. Ann Intensive Care. 2022 Oct 5;12(1):93. doi: 10.1186/s13613-022-01067-9. PMID: 36195759.
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Impella vs. VA-ECMO for Cardiogenic Shock after a Myocardial Infarction

Check out this paper about Impella vs. VA-ECMO for Cardiogenic Shock after an MI HERE.

ECPella: VA ECMO + Impella

ECPella is when we use Impella on top of VA-ECMO. Rather than go through it myself, a fantastic review article was published on the matter. This was updated on 1/27/22.

Meani P, Lorusso R, Pappalardo F. ECPella: Concept, Physiology and Clinical Applications. J Cardiothorac Vasc Anesth. 2022 Feb;36(2):557-566. doi: 10.1053/j.jvca.2021.01.056. Epub 2021 Feb 6. PMID: 33642170.
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Right Ventricular Support

The article shared on Instagram on 5/8/21
Grignola JC, Domingo E. Acute Right Ventricular Dysfunction in Intensive Care Unit. Biomed Res Int. 2017;2017:8217105. doi: 10.1155/2017/8217105. Epub 2017 Oct 19. PMID: 29201914; PMCID: PMC5671685.
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Citations Looking at Cardiogenic Shock

Hajjar LA, Teboul JL. Mechanical Circulatory Support Devices for Cardiogenic Shock: State of the Art. Crit Care. 2019 Mar 9;23(1):76. doi: 10.1186/s13054-019-2368-y. PMID: 30850001; PMCID: PMC6408785.
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Papolos AI, Kenigsberg BB, Berg DD, Alviar CL, Bohula E, Burke JA, Carnicelli AP, Chaudhry SP, Drakos S, Gerber DA, Guo J, Horowitz JM, Katz JN, Keeley EC, Metkus TS, Nativi-Nicolau J, Snell JR, Sinha SS, Tymchak WJ, Van Diepen S, Morrow DA, Barnett CF; Critical Care Cardiology Trials Network Investigators. Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams. J Am Coll Cardiol. 2021 Sep 28;78(13):1309-1317. doi: 10.1016/j.jacc.2021.07.044. PMID: 34556316.
Link to Article (NOT FREE)

Lobo AS, Sandoval Y, Henriques JP, Drakos SG, Taleb I, Bagai J, Cohen MG, Chatzizisis YS, Sun B, Hryniewicz K, Eckman PM, Thiele H, Brilakis ES. Cardiogenic Shock Management: International Survey of Contemporary Practices. J Invasive Cardiol. 2020 Oct;32(10):371-374. PMID: 32999090.
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Jones TL, Nakamura K, McCabe JM. Cardiogenic shock: evolving definitions and future directions in management. Open Heart. 2019 May 8;6(1):e000960. doi: 10.1136/openhrt-2018-000960. PMID: 31168376; PMCID: PMC6519403.
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Squara P, Hollenberg S, Payen D. Reconsidering Vasopressors for Cardiogenic Shock: Everything Should Be Made as Simple as Possible, but Not Simpler. Chest. 2019 Aug;156(2):392-401. doi: 10.1016/j.chest.2019.03.020. Epub 2019 Mar 29. PMID: 30935893.
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Vahdatpour C, Collins D, Goldberg S. Cardiogenic Shock. J Am Heart Assoc. 2019 Apr 16;8(8):e011991. doi: 10.1161/JAHA.119.011991. PMID: 30947630; PMCID: PMC6507212.
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Fryer ML, Balsam LB. Mechanical Circulatory Support for Cardiogenic Shock in the Critically Ill. Chest. 2019 Nov;156(5):1008-1021. doi: 10.1016/j.chest.2019.07.009. Epub 2019 Jul 30. PMID: 31374209.
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Samsky M, Krucoff M, Althouse AD, Abraham WT, Adamson P, Aguel F, Bilazarian S, Dangas GD, Gilchrist IC, Henry TD, Hochman JS, Kapur NK, Laschinger J, Masters RG, Michelson E, Morrow DA, Morrow V, Ohman EM, Pina I, Proudfoot AG, Rogers J, Sapirstein J, Senatore F, Stockbridge N, Thiele H, Truesdell AG, Waksman R, Rao S. Clinical and regulatory landscape for cardiogenic shock: A report from the Cardiac Safety Research Consortium ThinkTank on cardiogenic shock. Am Heart J. 2020 Jan;219:1-8. doi: 10.1016/j.ahj.2019.10.006. Epub 2019 Nov 7. PMID: 31707323; PMCID: PMC7604661.
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Fincke R, Hochman JS, Lowe AM, Menon V, Slater JN, Webb JG, LeJemtel TH, Cotter G; SHOCK Investigators. Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry. J Am Coll Cardiol. 2004 Jul 21;44(2):340-8. doi: 10.1016/j.jacc.2004.03.060. PMID: 15261929.
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Lim HS. Cardiac Power Output Revisited. Circ Heart Fail. 2020 Oct;13(10):e007393. doi: 10.1161/CIRCHEARTFAILURE.120.007393. Epub 2020 Sep 30. PMID: 32993372.
Link to NOT FREE Article

Basir MB, Kapur NK, Patel K, Salam MA, Schreiber T, Kaki A, Hanson I, Almany S, Timmis S, Dixon S, Kolski B, Todd J, Senter S, Marso S, Lasorda D, Wilkins C, Lalonde T, Attallah A, Larkin T, Dupont A, Marshall J, Patel N, Overly T, Green M, Tehrani B, Truesdell AG, Sharma R, Akhtar Y, McRae T 3rd, O’Neill B, Finley J, Rahman A, Foster M, Askari R, Goldsweig A, Martin S, Bharadwaj A, Khuddus M, Caputo C, Korpas D, Cawich I, McAllister D, Blank N, Alraies MC, Fisher R, Khandelwal A, Alaswad K, Lemor A, Johnson T, Hacala M, O’Neill WW; National Cardiogenic Shock Initiative Investigators. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019 Jun 1;93(7):1173-1183. doi: 10.1002/ccd.28307. Epub 2019 Apr 25. PMID: 31025538.
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Tehrani BN, Truesdell AG, Sherwood MW, Desai S, Tran HA, Epps KC, Singh R, Psotka M, Shah P, Cooper LB, Rosner C, Raja A, Barnett SD, Saulino P, deFilippi CR, Gurbel PA, Murphy CE, O’Connor CM. Standardized Team-Based Care for Cardiogenic Shock. J Am Coll Cardiol. 2019 Apr 9;73(13):1659-1669. doi: 10.1016/j.jacc.2018.12.084. Erratum in: J Am Coll Cardiol. 2019 Jul 23;74(3):481. PMID: 30947919.
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Basir MB, Schreiber TL, Grines CL, Dixon SR, Moses JW, Maini BS, Khandelwal AK, Ohman EM, O’Neill WW. Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock. Am J Cardiol. 2017 Mar 15;119(6):845-851. doi: 10.1016/j.amjcard.2016.11.037. Epub 2016 Dec 18. PMID: 28040188.
Link to Article

Miller PE, Solomon MA, McAreavey D. Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock. Crit Care Med. 2017 Nov;45(11):1922-1929. doi: 10.1097/CCM.0000000000002676. PMID: 28857849; PMCID: PMC5640487.
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Intraaortic Balloon Pump Citations

Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm M, Ebelt H, Schneider S, Schuler G, Werdan K; IABP-SHOCK II Trial Investigators. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012 Oct 4;367(14):1287-96. doi: 10.1056/NEJMoa1208410. Epub 2012 Aug 26. PMID: 22920912.
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Romeo F, Acconcia MC, Sergi D, Romeo A, Muscoli S, Valente S, Gensini GF, Chiarotti F, Caretta Q. The outcome of intra-aortic balloon pump support in acute myocardial infarction complicated by cardiogenic shock according to the type of revascularization: a comprehensive meta-analysis. Am Heart J. 2013 May;165(5):679-92. doi: 10.1016/j.ahj.2013.02.020. Epub 2013 Mar 26. PMID: 23622904.
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Aso S, Matsui H, Fushimi K, Yasunaga H. The Effect of Intraaortic Balloon Pumping Under Venoarterial Extracorporeal Membrane Oxygenation on Mortality of Cardiogenic Patients: An Analysis Using a Nationwide Inpatient Database. Crit Care Med. 2016 Nov;44(11):1974-1979. doi: 10.1097/CCM.0000000000001828. PMID: 27322361.
Link to Article

Shah M, Patnaik S, Patel B, Ram P, Garg L, Agarwal M, Agrawal S, Arora S, Patel N, Wald J, Jorde UP. Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States. Clin Res Cardiol. 2018 Apr;107(4):287-303. doi: 10.1007/s00392-017-1182-2. Epub 2017 Nov 13. PMID: 29134345.
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Seyfarth M, Sibbing D, Bauer I, Fröhlich G, Bott-Flügel L, Byrne R, Dirschinger J, Kastrati A, Schömig A. A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction. J Am Coll Cardiol. 2008 Nov 4;52(19):1584-8. doi: 10.1016/j.jacc.2008.05.065. PMID: 19007597.
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Heringlake M, Berggreen AE, Paarmann H. Still a place for aortic counterpulsation in cardiac surgery and patients with cardiogenic shock? Crit Care. 2021 Aug 31;25(1):309. doi: 10.1186/s13054-021-03673-8. PMID: 34461956; PMCID: PMC8407061.
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Impella Citations:

Vargas KG, Jäger B, Kaufmann CC, Biagioli A, Watremez S, Gatto F, Özbek C, Razouk A, Geppert A, Huber K. Impella in cardiogenic shock following acute myocardial infarction: a systematic review and meta-analysis. Wien Klin Wochenschr. 2020 Dec;132(23-24):716-725. doi: 10.1007/s00508-020-01712-y. Epub 2020 Jul 20. PMID: 32691215.
Link to NOT FREE Article

O’Neill WW, Kleiman NS, Moses J, Henriques JP, Dixon S, Massaro J, Palacios I, Maini B, Mulukutla S, Dzavík V, Popma J, Douglas PS, Ohman M. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study. Circulation. 2012 Oct 2;126(14):1717-27. doi: 10.1161/CIRCULATIONAHA.112.098194. Epub 2012 Aug 30. PMID: 22935569.
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Lauten A, Engström AE, Jung C, Empen K, Erne P, Cook S, Windecker S, Bergmann MW, Klingenberg R, Lüscher TF, Haude M, Rulands D, Butter C, Ullman B, Hellgren L, Modena MG, Pedrazzini G, Henriques JP, Figulla HR, Ferrari M. Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry. Circ Heart Fail. 2013 Jan;6(1):23-30. doi: 10.1161/CIRCHEARTFAILURE.112.967224. Epub 2012 Dec 4. PMID: 23212552.
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Ouweneel DM, Eriksen E, Sjauw KD, van Dongen IM, Hirsch A, Packer EJ, Vis MM, Wykrzykowska JJ, Koch KT, Baan J, de Winter RJ, Piek JJ, Lagrand WK, de Mol BA, Tijssen JG, Henriques JP. Percutaneous Mechanical Circulatory Support Versus Intra-Aortic Balloon Pump in Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol. 2017 Jan 24;69(3):278-287. doi: 10.1016/j.jacc.2016.10.022. Epub 2016 Oct 31. PMID: 27810347.
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Engström AE, Cocchieri R, Driessen AH, Sjauw KD, Vis MM, Baan J, de Jong M, Lagrand WK, van der Sloot JA, Tijssen JG, de Winter RJ, de Mol BA, Piek JJ, Henriques JP. The Impella 2.5 and 5.0 devices for ST-elevation myocardial infarction patients presenting with severe and profound cardiogenic shock: the Academic Medical Center intensive care unit experience. Crit Care Med. 2011 Sep;39(9):2072-9. doi: 10.1097/CCM.0b013e31821e89b5. PMID: 21602670.
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Lemaire A, Anderson MB, Lee LY, Scholz P, Prendergast T, Goodman A, Lozano AM, Spotnitz A, Batsides G. The Impella device for acute mechanical circulatory support in patients in cardiogenic shock. Ann Thorac Surg. 2014 Jan;97(1):133-8. doi: 10.1016/j.athoracsur.2013.07.053. Epub 2013 Oct 1. PMID: 24090575.
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Lemor A, Hosseini Dehkordi SH, Basir MB, Villablanca PA, Jain T, Koenig GC, Alaswad K, Moses JW, Kapur NK, O’Neill W. Impella Versus Extracorporeal Membrane Oxygenation for Acute Myocardial Infarction Cardiogenic Shock. Cardiovasc Revasc Med. 2020 Dec;21(12):1465-1471. doi: 10.1016/j.carrev.2020.05.042. Epub 2020 May 30. PMID: 32605901.
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Griffith BP, Anderson MB, Samuels LE, Pae WE Jr, Naka Y, Frazier OH. The RECOVER I: a multicenter prospective study of Impella 5.0/LD for postcardiotomy circulatory support. J Thorac Cardiovasc Surg. 2013 Feb;145(2):548-54. doi: 10.1016/j.jtcvs.2012.01.067. Epub 2012 Mar 9. PMID: 22405676.
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Basir MB, Schreiber T, Dixon S, Alaswad K, Patel K, Almany S, Khandelwal A, Hanson I, George A, Ashbrook M, Blank N, Abdelsalam M, Sareen N, Timmis SBH, O’Neill Md WW. Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative. Catheter Cardiovasc Interv. 2018 Feb 15;91(3):454-461. doi: 10.1002/ccd.27427. Epub 2017 Dec 20. PMID: 29266676.
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Lamarche Y, Cheung A, Ignaszewski A, Higgins J, Kaan A, Griesdale DE, Moss R. Comparative outcomes in cardiogenic shock patients managed with Impella microaxial pump or extracorporeal life support. J Thorac Cardiovasc Surg. 2011 Jul;142(1):60-5. doi: 10.1016/j.jtcvs.2010.07.075. Epub 2010 Sep 28. PMID: 20880553.
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Thiele H, Sick P, Boudriot E, Diederich KW, Hambrecht R, Niebauer J, Schuler G. Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J. 2005 Jul;26(13):1276-83. doi: 10.1093/eurheartj/ehi161. Epub 2005 Feb 25. PMID: 15734771.
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TandemHeart Citations

Burkhoff D, Cohen H, Brunckhorst C, O’Neill WW; TandemHeart Investigators Group. A randomized multicenter clinical study to evaluate the safety and efficacy of the TandemHeart percutaneous ventricular assist device versus conventional therapy with intraaortic balloon pumping for treatment of cardiogenic shock. Am Heart J. 2006 Sep;152(3):469.e1-8. doi: 10.1016/j.ahj.2006.05.031. PMID: 16923414.
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Kar B, Gregoric ID, Basra SS, Idelchik GM, Loyalka P. The percutaneous ventricular assist device in severe refractory cardiogenic shock. J Am Coll Cardiol. 2011 Feb 8;57(6):688-96. doi: 10.1016/j.jacc.2010.08.613. Epub 2010 Oct 14. PMID: 20950980.
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VA-ECMO Citations

Makdisi G, Wang IW. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis. 2015 Jul;7(7):E166-76. doi: 10.3978/j.issn.2072-1439.2015.07.17. PMID: 26380745; PMCID: PMC4522501.
I have reviewed this article in the past. Click HERE to check it out.
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Sheu JJ, Tsai TH, Lee FY, Fang HY, Sun CK, Leu S, Yang CH, Chen SM, Hang CL, Hsieh YK, Chen CJ, Wu CJ, Yip HK. Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock. Crit Care Med. 2010 Sep;38(9):1810-7. doi: 10.1097/CCM.0b013e3181e8acf7. PMID: 20543669.
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Ventetuolo CE, Muratore CS. Extracorporeal life support in critically ill adults. Am J Respir Crit Care Med. 2014 Sep 1;190(5):497-508. doi: 10.1164/rccm.201404-0736CI. PMID: 25046529; PMCID: PMC4214087.
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Mirabel M, Luyt CE, Leprince P, Trouillet JL, Léger P, Pavie A, Chastre J, Combes A. Outcomes, long-term quality of life, and psychologic assessment of fulminant myocarditis patients rescued by mechanical circulatory support. Crit Care Med. 2011 May;39(5):1029-35. doi: 10.1097/CCM.0b013e31820ead45. PMID: 21336134.
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Xie A, Phan K, Tsai YC, Yan TD, Forrest P. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: a meta-analysis. J Cardiothorac Vasc Anesth. 2015;29(3):637-45. doi: 10.1053/j.jvca.2014.09.005. Epub 2014 Dec 24. PMID: 25543217.
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Cheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, Esmailian F, Azarbal B. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014 Feb;97(2):610-6. doi: 10.1016/j.athoracsur.2013.09.008. Epub 2013 Nov 8. PMID: 24210621.
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Truby LK, Takeda K, Mauro C, Yuzefpolskaya M, Garan AR, Kirtane AJ, Topkara VK, Abrams D, Brodie D, Colombo PC, Naka Y, Takayama H. Incidence and Implications of Left Ventricular Distention During Venoarterial Extracorporeal Membrane Oxygenation Support. ASAIO J. 2017 May/Jun;63(3):257-265. doi: 10.1097/MAT.0000000000000553. PMID: 28422817.
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Pappalardo F, Schulte C, Pieri M, Schrage B, Contri R, Soeffker G, Greco T, Lembo R, Müllerleile K, Colombo A, Sydow K, De Bonis M, Wagner F, Reichenspurner H, Blankenberg S, Zangrillo A, Westermann D. Concomitant implantation of Impella^® on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock. Eur J Heart Fail. 2017 Mar;19(3):404-412. doi: 10.1002/ejhf.668. Epub 2016 Oct 6. PMID: 27709750.
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Right Ventricular Assist Devices for Cardiogenic Shock Citations

Grignola JC, Domingo E. Acute Right Ventricular Dysfunction in Intensive Care Unit. Biomed Res Int. 2017;2017:8217105. doi: 10.1155/2017/8217105. Epub 2017 Oct 19. PMID: 29201914; PMCID: PMC5671685.
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Anderson MB, Goldstein J, Milano C, Morris LD, Kormos RL, Bhama J, Kapur NK, Bansal A, Garcia J, Baker JN, Silvestry S, Holman WL, Douglas PS, O’Neill W. Benefits of a novel percutaneous ventricular assist device for right heart failure: The prospective RECOVER RIGHT study of the Impella RP device. J Heart Lung Transplant. 2015 Dec;34(12):1549-60. doi: 10.1016/j.healun.2015.08.018. Epub 2015 Sep 8. PMID: 26681124.
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Anderson M, Morris DL, Tang D, Batsides G, Kirtane A, Hanson I, Meraj P, Kapur NK, O’Neill W. Outcomes of patients with right ventricular failure requiring short-term hemodynamic support with the Impella RP device. J Heart Lung Transplant. 2018 Dec;37(12):1448-1458. doi: 10.1016/j.healun.2018.08.001. Epub 2018 Aug 8. PMID: 30241890.
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Ravichandran AK, Baran DA, Stelling K, Cowger JA, Salerno CT. Outcomes with the Tandem Protek Duo Dual-Lumen Percutaneous Right Ventricular Assist Device. ASAIO J. 2018 Jul/Aug;64(4):570-572. doi: 10.1097/MAT.0000000000000709. PMID: 29095736.
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I cover Protek Duo in depth HERE.

Aggarwal V, Einhorn BN, Cohen HA. Current status of percutaneous right ventricular assist devices: First-in-man use of a novel dual lumen cannula. Catheter Cardiovasc Interv. 2016 Sep;88(3):390-6. doi: 10.1002/ccd.26348. Epub 2016 Feb 20. PMID: 26895620.
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I cover Protek Duo in depth HERE.

Subramaniam AV, Barsness GW, Vallabhajosyula S, Vallabhajosyula S. Complications of Temporary Percutaneous Mechanical Circulatory Support for Cardiogenic Shock: An Appraisal of Contemporary Literature. Cardiol Ther. 2019 Dec;8(2):211-228. doi: 10.1007/s40119-019-00152-8. Epub 2019 Oct 23. PMID: 31646440; PMCID: PMC6828896.
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Garan AR, Kanwar M, Thayer KL, Whitehead E, Zweck E, Hernandez-Montfort J, Mahr C, Haywood JL, Harwani NM, Wencker D, Sinha SS, Vorovich E, Abraham J, O’Neill W, Burkhoff D, Kapur NK. Complete Hemodynamic Profiling With Pulmonary Artery Catheters in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. JACC Heart Fail. 2020 Nov;8(11):903-913. doi: 10.1016/j.jchf.2020.08.012. PMID: 33121702.
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Wayangankar SA, Bangalore S, McCoy LA, Jneid H, Latif F, Karrowni W, Charitakis K, Feldman DN, Dakik HA, Mauri L, Peterson ED, Messenger J, Roe M, Mukherjee D, Klein A. Temporal Trends and Outcomes of Patients Undergoing Percutaneous Coronary Interventions for Cardiogenic Shock in the Setting of Acute Myocardial Infarction: A Report From the CathPCI Registry. JACC Cardiovasc Interv. 2016 Feb 22;9(4):341-351. doi: 10.1016/j.jcin.2015.10.039. Epub 2016 Jan 20. PMID: 26803418.
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How to Support My Work on Cardiogenic Shock

I have written “The Vasopressor & Inotrope Handbook: A Practical Guide for Healthcare Professionals,” a must-read for those in the field! You have several options to get a copy while supporting my endeavors. If you’re in the US, you can order directly from me with a special touch: A SIGNED COPY. Please note that I handle these shipments personally, so I appreciate your patience.

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Disclaimer

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