From Medical Therapy to Mechanical Support – Strategies for Device Selection and Insertion Techniques

In “From Medical Therapy to Mechanical Support – Strategies for Device Selection and Insertion Techniques” published in European Heart Journal, Letizia Bertoldi, MD, and colleagues describe how catecholamines and percutaneous ventricular assist devices (pVADs) are used to treat cardiogenic shock (CS) according to underlying etiology. They also discuss best practices for pVAD insertion.
The authors explain that while inotropes and vasopressors are often considered the cornerstone of CS therapy, these pharmacologic agents “are typically limited by an imbalance between myocardial oxygen supply and demand, as well as metabolic derangements.” They describe a cardioprotective vision of CS management with a paradigm shift toward an “inotrope-free strategy” and early insertion of pVADs to allow the myocardium to rest (unload) to maximize the chance for recovery. They write, “The most recent guidelines from the European Society of Cardiology emphasize this concept by assigning to pVAD the highest class of recommendation (as compared to inotropes) as first line strategy in CS management (IIa vs. IIb).”

Based on evidence in the literature and expert consensus, Bertoldi et al. propose an algorithm for practical management of inotropes in CS as well as an algorithm for selection of pVADs in patients with CS. The authors explain that in-hospital mortality rates are significantly higher in patients with higher vasoactive-inotropic score (VIS), and if VIS is included in management algorithms it could help standardize the degree of hemodynamic support across institutions and could help clinicians identify patients who might benefit from escalation of support.