Current status of percutaneous ventricular assist devices for cardiogenic shock

Percutaneous ventricular assist devices (pVADs) are being increasingly used in patients with cardiogenic shock. They offer a means of instituting rapid and adequate cardiac support in patients with cardiogenic shock unresponsive to inotropes/vasopressors and intraaortic balloon pumps (IABPs). However, there is considerable debate on the appropriate use of these devices given the difficulty of conducting randomized trials in patients with cardiogenic shock, lack of clear guidelines on indications, device selection, and cost-effective care of patients implanted with these devices.

Several centers have recently reported data on the use of these devices for cardiogenic shock in a variety of different settings, including myocardial ischemia and its complications, high-risk percutaneous coronary intervention, myocarditis, and refractory arrhythmias. Recent randomized trials have compared the use of IABP with different pVADs evaluating hemodynamic outcomes as well as short-term mortality.

We review the current evidence on the use of pVADs (Tandemheart pVAD, Impella, percutaneous extracorporeal membrane oxygenation), their indications, relative merits, and adverse effects, and discuss the current approach to the appropriate use of pVADs in patients with cardiogenic shock. We also propose an algorithm for device selection tailored to each patient's needs based on severity of cardiogenic shock, amount of support needed, and the overall clinical scenario.