Algorithms, Escalation Therapy, AMI Cardiogenic Shock

Interview with Dr. Letizia Bertoldi : Algorithm for MCS Selection in Cardiogenic Shock


Letizia Bertoldi, M.D., discusses a paper in which she and her colleagues developed an algorithm for practical management of patients with cardiogenic shock. Dr. Bertoldi is the first author of “From Medical Therapy to Mechanical Support – Strategies for Device Selection and Implantation Techniques.” This is one of eight articles published in the European Heart Journal Supplement “From Patient Selection to Escalation Strategies: Mechanical Circulatory Support in Cardiogenic Shock.”

Dr. Bertoldi discusses the correlation between stages of cardiogenic shock and selection of inotropes and percutaneous ventricular assist devices (pVADs) to treat cardiogenic shock. She explains how inotropes can negatively impact myocardial recovery and end organs and states, “In our cardioprotective vision of cardiogenic shock management, the strategy should be based on the primary unloading of the ventricle in order to maximize the chance for recovery.” 

Noting that vasoactive inotropic score (VIS) correlates with in-hospital mortality, Dr. Bertoldi explains that in their paper they propose an algorithm in which VIS and SCAI shock stage guide selection of treatment for patients in cardiogenic shock. In addition, MCS selection is guided by the urgent or emergent need for device implantation, the etiology of cardiogenic shock, the potential for heart recovery, the predicted duration of support, right ventricular (RV) function, presence of device contraindications and the expertise of treating physicians. 

Dr. Bertoldi discusses MCS selection in three types of patients. In patients with SCAI stage C acute myocardial infarction cardiogenic shock (AMICS), she explains that the primary goals of therapy are to achieve hemodynamic stabilization, unload the LV and create optimal conditions for coronary revascularization. In this setting, the first-choice device is percutaneous MCS that can be implanted quickly. In patients with SCAI D or E shock or refractory cardiac arrest, the goal is to immediately stabilize the patient; veno-arterial extracorporeal membrane oxygenation (VA ECMO) is a first choice with early consideration of escalation to ECMELLA (VA ECMO plus Impella®) for LV unloading. In the setting of acute decompensated heart failure (ADHF) cardiogenic shock, patients often have end organ dysfunction and may require prolonged support; therefore, the first choice is axillary insertion of Impella, such as Impella 5.5®, which allow patients to ambulate.

Dr. Bertoldi concludes with a discussion of best practices for minimizing vascular access and bleeding complications in patients supported with MCS.

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