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Updated: Apr 11, 2026
Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Mechanical circulatory support in cardiogenic shock
Karl Werdan1, Stephan Gielen, Henning Ebelt
1Department of Internal Medicine III, Heart Center, Martin-Luther-University Halle-Wittenberg, University Hospital Halle/Saale, Ernst-Grube-Str. 40, Halle/Saale 06120, Germany.
Insights
Mechanical circulatory support for cardiogenic shock complicating acute ST-elevation myocardial infarction (CSMI) is crucial but current devices, including IABP, ECMO, Impella, and TandemHeart, have not improved survival rates. Further research into optimal device timing and design is needed for better CSMI outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Critical Care Medicine
Background:
- Cardiogenic shock complicating acute ST-elevation myocardial infarction (CSMI) presents a significant clinical challenge with high mortality.
- While mechanical circulatory support (MCS) is increasingly used, conservative management with catecholamines has limitations.
- Percutaneous assist systems offer various circulatory support types, including intra-aortic balloon pumps (IABP), extracorporeal membrane oxygenation (ECMO), Impella, and TandemHeart.
Purpose of the Study:
- To review the current landscape of mechanical circulatory support devices used in CSMI.
- To evaluate the efficacy of commonly used percutaneous assist systems in improving outcomes for CSMI patients.
- To identify gaps in current research and suggest future directions for improving CSMI management.
Main Methods:
- Review of clinical studies and experience with hemodynamic improvement.
- Analysis of data from the IABP-Shock II Trial regarding IABP use in CSMI.
- Examination of randomized controlled trials (RCTs) comparing Impella and TandemHeart to IABP.
Main Results:
- Decades of experience show hemodynamic improvements with MCS, but recent trials have yielded disappointing survival results.
- The IABP-Shock II Trial found no significant reduction in 30-day mortality for CSMI patients treated with IABP.
- Small RCTs indicated that Impella and TandemHeart did not reduce 30-day mortality compared to IABP.
Conclusions:
- Current percutaneous mechanical circulatory support devices, as tested, have not demonstrated improved short- or long-term survival rates in CSMI.
- There is a critical need for well-designed RCTs to investigate optimal timing and device design for MCS in CSMI.
- Further research is essential to enhance patient outcomes in cardiogenic shock complicating myocardial infarction.
Abstract:
Despite advances in coronary revascularization and widespread use of primary percutaneous interventions, cardiogenic shock complicating an acute ST-elevation myocardial infarction (CSMI) remains a clinical challenge with high mortality rates. Conservative management with catecholamines is associated with serious limitations, including arrhythmias, increased myocardial oxygen consumption, and inadequate circulatory support. Clinicians have therefore turned to mechanical means of circulatory support. Circulatory assist systems for CSMI can be distinguished by the method of placement (i.e. percutaneous vs. surgical), the type of circulatory support (i.e. left ventricular, right ventricular, or biventricular pressure and/or volume unloading), and whether they are combined with extracorporal membrane oxygenation (ECMO). The percutaneous assist systems most commonly used in CSMI are the intra-aortic balloon pump (IABP), venoarterial ECMO, the Impella pump, and the TandemHeart. Decades of clinical studies and experience demonstrated haemodynamic improvement, including elevation of diastolic perfusion pressure and cardiac output. Recently, the large randomized IABP-Shock II Trial did not show a significant reduction in 30-day mortality in CSMI with IABP insertion. There are no randomized study data available for ECMO use in CSMI. Both the Impella pump and the TandemHeart did not reduce 30-day mortality when compared with IABP in small randomized controlled trials (RCTs). In conclusion, despite the need for effective mechanical circulatory support in CSMI, current devices, as tested, have not been demonstrated to improve short- or long-term survival rates. RCTs testing the optimal timing of device therapy and optimal device design are needed to improve outcomes in CSMI.
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