CLINICAL
NEWS IN FOCUS
An Algorithm for Mechanical Circulatory Support (MCS) Devices
Tami Atkinson, MD, Joaquin Cigarroa, MD, and Tanveer Rab, MD
M
echanical circulatory support (MCS)
devices have been used to stabilize
patients with cardiogenic shock and
high-risk percutaneous coronary interventions
(HR-PCI) for decades. While the intra-aortic balloon
pump (IABP) has been the mainstay, percutaneous
mechanical circulatory support devices such as
veno-arterial extracorporeal membrane oxygenation
(VA-ECMO), Impella, and TandemHeart have been
developed and offer higher levels of hemodynamic
support.1,2 With the application of percutaneous
coronary intervention (PCI) to higher risk and hemodynamically unstable patients, the role for MCS
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CardioSource WorldNews: Interventions
has expanded.3 MCS devices offer significant improvement in hemodynamics with less hypotensive
events and improved cardiac power compared to
IABP.4-7 While hemodynamic improvement has not
translated into a mortality benefit, it enhances the
operator’s ability to provide complete revascularization in challenging subsets of patients.8 Recently,
the FDA expanded the indications for Impella devices to include their use in cardiogenic shock after
myocardial infarction or open-heart surgery.
With multiple device therapies available,
decision-making in complex and hemodynamically
unstable patients is challenging. An algorithm
(attached illustration) recently published in JACC
Cardiovascular Interventions, was developed to
guide interventional cardiologists in decision making for MCS device therapy in patients undergoing
PCI with high-risk features or cardiogenic shock.9
The first step recommends prompt identification
of patients with cardiogenic shock, cardiac arrest,
or high-risk features. When feasible, the next step
endorses a multidisciplinary heart team consultation, which encompasses interventional cardiology, cardiothoracic surgery, advanced heart failure
and intensive care physicians. After heart team
consultation, the operator can work through the
July/August 2016