Analysis of the 2023 European Multidisciplinary Consensus Statement on the Management of Short-term Mechanical Circulatory Support of Cardiogenic Shock in Adults in the Intensive Cardiac Care Unit
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Abstract
DESPITE MEDICAL ADVANCEMENTS, mortality in cardiogenic shock (CS) remains unacceptably high.The decreased cardiac output resulting in impaired oxygen delivery characteristic of CS triggers a dismal cascade culminating in tissue hypoperfusion, multiorgan failure, and death without early intervention.
Given the scarcity of interventions to alleviate this harmful progression, there has been a notable increase in the utilization of percutaneous mechanical circulatory support (pMCS) devices aimed at restoring blood flow and oxygen delivery despite limited evidence supporting their efficacy.
The current evidence, largely based on conflicting retrospective studies, expert consensus, and small randomized controlled trials (RCTs), presents challenges in evaluating the effectiveness of these invasive and cost-intensive devices.
The two largest RCTs to date assessing percutaneous venoarterial (VA) extracorporeal membrane oxygenation (ECMO) in noncardiac arrest situations have not demonstrated mortality benefits. These outcomes are not entirely surprising as RCTs face inherent limitations due to the heterogeneous nature of CS, encompassing diverse etiologies and phenotypes, severity gradations, evolution of the diagnostic criteria for CS, and frequent transitions of study patients from conventional care to mechanical circulatory support.
Despite these challenges, in a recent well-conducted trial, the routine implementation of intracorporeal axial flow pumps (AFPs) in a highly selective group of patients experiencing acute ST-segment elevation myocardial infarction complicated by CS exhibited a significant mortality benefit but with a higher incidence of complications compared with standard care alone.
Initiation and deployment of these devices is technically complex and resource-intensive, with institutional experience and healthcare system factors impacting outcomes.
These complexities contribute to difficulty in designing trials, significant confounding and, ultimately, pose challenges in interpreting outcomes.
It also provides a brief discussion of the pertinent supporting literature to provide a guide for clinicians caring for these patients.