Imran Aslam, MD Duke University

1. Mechanical Circulatory Support Devices
in the Management of
Cardiogenic Shock
M. Imran Aslam, MD
Assistant Professor of Medicine
Interventional / Advanced Heart Failure & Transplant
Cardiology

2. Disclosures
• I have no relevant financial disclosures.

3. Clinical Course of HF Influences Presentation of CS
Acute Myocardial Infarction
• ↓Cardiac Output (CO) resulting in
↓perfusion, ↑pulmonary & systemic
congestion from ↑cardiac filling
pressures
• Characterized in a non-invasive (e.g.
exam, labs, imaging) and invasive
(e.g. right heart catheterization)
manner
• Mortality remains ↑ (40-60%)
• Variable management strategies
(pharmacological or mechanical)
• How you decompensate depends on
the etiology of CS
• This ultimately influences the choice
and response to intervention(s)
Modified from Truby & Rogers. JACC: Heart Failure. 2020

4. • When: Failure to decongest and restore adequate perfusion
(e.g. ↓UOP, WRF, ↑Lactate, end-organ dysfunction)
• Why: Two primary goals-
1) Increase mean arterial pressure (MAP) and vital organ
perfusion
2) Reduce ventricular pressure and volume, thereby ↓ wall
stress, stroke work and myocardial O2 consumption
(‘ventricular unloading’)
• Device use facilitates these goals by providing Mechanical
Circulatory Support (MCS)
• Can assist the left ventricle (LV), the right ventricle (RV) or
both
Using Devices to Treat CS

5. Devices for the LV: Intra-Aortic Balloon Pump (IABP)
Modified from Thoracic Key
• Inflates in diastole (pushing blood
towards aortic root to ↑coronary
perfusion)
• Rapid deflation before systole, ↓LV
work, ↑MAP and organ perfusion with
↓afterload
• 1:1 timing with the cardiac cycle
• ↑Balloon size  ↑Support
• Typically most effective in those with
long-standing HF presenting with CS,
and less effective in CS in the setting
of acute MI
• Little/no effect on RV
Femoral Axillary
Percutaneous Placement
(8-9 Fr)
Femoral Axillary

6. Devices for the LV: Impella
• Continuous, axial flow device
across the aortic valve (AV)
• Escalating support provided by
↑P level (1-9); maximal support:
3 to <4 L/min for Impella CP
• ↓Wall stress by direct ↓ in LV
pressure
• ↑Coronary perfusion, ↑ MAP/organ
perfusion
• Little/no effect on RV
Impella CP
(Percutaneous Placement)
14 Fr, Femoral/Axillary
Impella 5.5
(Surgical Placement)
19 Fr, Axillary
Up to 6 L/min support
Credit: Abiomed

7. Devices for the RV: Impella RP
Percutaneous Placement
22 Fr sheath, downsized to 15 Fr Venous
• Continuous, axial flow device
across the tricuspid/pulmonic valve
• Escalating support provided by
↑P level (1-9); maximal support:
3 to <4 L/min
• Right Atrium (RA) to Pulmonary
Artery (PA) bypass
• ↑MAP/organ perfusion
• LV has to be able to accommodate
increased flow to avoid pulmonary
edema/hemorrhage
• Less forgiving to be off/low anti-
coagulation goals compared to
other RA-PA bypass devices
Credit: Abiomed

8. Devices for the RV: ProtekDuo / Spectrum
Percutaneous Placement
29/31 Fr Venous
• Pump function is extra-corporeal
(continuous flow centrifugal pump)
• Use when needing >3 L/min of
support (up to 4-5 L/min) or ability
to oxygenate
• RA to PA bypass
• ↑MAP/organ perfusion
• LV has to be able to accommodate
increased flow to avoid pulmonary
edema/hemorrhage
Credit: Spectrum Medical

9. Bi-Ventricular Support: ECMO
• Pump function is extra-corporeal
(continuous flow centrifugal pump)
• When ‘full support’ is needed
and/or likelihood of hypoxia
• Decompresses RV
• ↑ MAP/organ perfusion
• ↑Wall stress by pressurizing aortic
root/↑afterload
• Equipoise regarding use of
concomitant LV assist device
(IABP or Impella) to ↓wall stress,
↓stasis/thrombus
Modified from De Charrière et al. J. Clin. Med. 10(2), 534 (2021)
Percutaneous Placement
15-17 Fr Arterial, 21-25 Fr
Venous
Aortic Root is
Pressurized
Retrograde
Blood Flow

10. Alternative Bi-Ventricular Support: LAVA ECMO
Percutaneous Placement
24 Fr Venous, 15-17 Fr Arterial
• Left Atrial-Veno-Arterial (LAVA)
ECMO
• ECMO with bi-ventricular
decompression in the setting of AV
pathology, LV thrombus and the
ability to oxygenate
• Requires septostomy
• ↑MAP/organ perfusion
• ↓Wall stress by direct reduction of
chamber pressures
Choi et al. Korean Circ J. Aug;49(8): (2019) 657-677

11. MCS Devices: Flow
Modified from Atkinson et al. JACC: CV Interventions. Vol. 9, No. 9 (2016) 871-883
Large bore: >5 mm
Impella 5.5
Impella CP/RP
Tandem, Protek/Spectrum

12. Devices for Heart Failure
Impella ECP “Expandable CP”
• 9Fr catheter (insertion and removal)
• Pump expands to 18 Fr
• Flows >3.5 L/min
• Under investigational use
Smaller MCS Devices Mitigating Future HF Events
Abiomed
TherOx SuperSaturated O2 (SSO2)
• Delivery of localized hyperoxemic
levels of O2 post LAD STEMI
• ↓Relative infarct size to ↓rate of
death and HF at 1 year
• Requires further study
TherOx/Zoll
Chen et al. CCI. 2021

13. Summary: Device use in CS
Decision
Making
Device
Placement
Aftercare Transition
Multi-Disciplinary
Team decision based
on objective data
(e.g. labs, RHC,
imaging), patient
candidacy
Each device has a
variable degree of
maximal support, risk
of hemolysis; Tailor to
patient situation,
where and when to
place
Post ICU care by
MCS-trained team,
frequent
reassessment for
improvement and
attention to possible
complications
Device use as a
bridge to recovery, or
advanced therapies
(provides time to
strategize, optimize
and/or await cardiac
transplantation)