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Acute cardiovascular care
Percutaneous mechanical circulatory support: current concepts and future directions
  1. Natalia Briceno1,
  2. Navin K Kapur2,
  3. Divaka Perera1
  1. 1Cardiovascular Division, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Rayne Institute, St Thomas’ Hospital Campus, King's College London, London, UK
  2. 2The Cardiovascular Center and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Divaka Perera, Cardiovascular Division, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Rayne Institute, St Thomas' Hospital Campus, King's College London, London SE1 7EH, UK; Divaka.Perera{at}kcl.ac.uk

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Learning objectives

  • To obtain a greater understanding of the role of mechanical circulatory support (MCS) in the current clinical arena.

  • To understand the physiology of cardiogenic shock and the varying physiological strategies employed by the current clinically available MCS devices and the existing evidence behind their use.

  • To develop an algorithm of MCS therapy, which can be used to optimise patient management.

Introduction

Percutaneous mechanical circulatory support (MCS) strategies have been in the clinical arena for approximately half a century, with the main aim of providing adequate systemic tissue perfusion, while also favourably impacting myocardial oxygen supply and demand, to optimise myocardial recovery in the face of cardiogenic shock (CS). This can be in the context of acute haemodynamic instability following a myocardial insult such as an acute coronary syndrome or myocarditis, or acute decompensation in a patient with chronic heart failure due to varying aetiologies. Despite major advances in both pharmacological and interventional therapies, CS continues to have a very poor prognosis with mortality rates in the order of 40%–80%.1–3 In addition to CS, MCS is more commonly being considered for patients with chronic heart failure undergoing high-risk percutaneous coronary intervention (PCI). This increasing population of ischaemic heart failure patients is due in part to improving survival after acute myocardial infarction (AMI), but with persistent myocardial damage despite timely reperfusion.4 In the setting of haemodynamic collapse, inotropes and vasopressors are often started immediately, due to their rapid onset of action. Although they differ in terms of their effects on systemic vascular resistance, these agents increase myocardial oxygen demand through their impact on adrenergic pathways.5 ,6 As a result, pharmacologic support can worsen mortality in CS and hence should only be used as a short-term means to achieve haemodynamic stability. In contrast to drug therapy, percutaneous MCS reduces myocardial …

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