Temporary Mechanical Circulatory Support in Patients in Cardiogenic Shock Requiring Cardiac Surgery: Protected Cardiac Surgery Concept
TL;DR
This review describes three clinical scenarios: preoperative stabilization and bridge-to-surgery, planned intraoperative support in patients at high risk of perioperative low cardiac output, and rescue support for failure to wean from cardiopulmonary bypass or postoperative heart failure.
Abstract
Temporary mechanical circulatory support (tMCS) has evolved as a first-line treatment of cardiogenic shock refractory to medical therapy. In recent years, tMCS has been applied to bridge and precondition end-stage heart failure patients with structural heart disease for surgery or intervention. This review describes three clinical scenarios: preoperative stabilization and bridge-to-surgery (Type 1), planned intraoperative support in patients at high risk of perioperative low cardiac output (Type 2), and rescue support for failure to wean from cardiopulmonary bypass or postoperative heart failure (Type 3). PubMed/MEDLINE was searched for publications from January 2017 onward. It discusses microaxial flow pumps (mAFP), intra-aortic balloon pumps (IABP), veno-arterial extracorporeal life support (VA-ECLS), and combined strategies, including left ventricular unloading during VA-ECLS. Clinical applications include acute myocardial infarction-related cardiogenic shock, acute mitral regurgitation, post-infarction ventricular septal defect and advanced heart failure therapy. Current European and American recommendations support early, individualized and Heart Team-guided use in selected patients. In this review, we aim to summarize the important aspects of protected tMCS implementation in cardiac surgery and highlight some recent evidence in this field.