Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025)

Algorithm Steps

1. ▶

   Start

   Postcardiotomy Cardiogenic Shock

   Failure to wean from CPB or post-op hemodynamic deterioration

   1. ●

      Action

      Initial Assessment

      Evaluate severity and optimize medical therapy

      • Confirm adequate surgical repair
      • Optimize preload (CVP, PCWP)
      • Optimize afterload (MAP, SVR)
      • Maximize inotropes: dobutamine, milrinone, epinephrine
      • Consider echo to assess function
      • Rule out tamponade, graft failure
      1. ◆

         Decision

         Shock Severity?

         Assess level of hemodynamic support needed

         • MODERATE: CI 1.8-2.2, lactate 2-4, single inotrope
         • SEVERE: CI <1.8, lactate >4, multiple inotropes
         • REFRACTORY: worsening despite maximum support
         1. ●

            Action

            IABP (Intra-Aortic Balloon Pump)

            First-line for moderate support

            • INDICATIONS:
            • • Moderate shock
            • • Ischemic cardiomyopathy
            • • Bridge during optimization
            • CONTRAINDICATIONS:
            • • Severe aortic regurgitation
            • • Aortic dissection
            • • Severe PAD
            • Provides 10-15% increase in CO
            • Reduces afterload, augments diastolic pressure
            1. ●

               Action

               Ongoing Management

               Monitor and optimize on support

               • Daily echo to assess recovery
               • Lactate clearance
               • End-organ function (renal, hepatic)
               • Anticoagulation (target ACT/aPTT)
               • Hemolysis monitoring (LDH, plasma-free Hb)
               • Limb perfusion (distal perfusion catheter for femoral)
               1. ◆

                  Decision

                  Weaning Assessment

                  Daily evaluation for recovery

                  • Criteria for weaning trial:
                  • • Improving echo (EF, contractility)
                  • • Lactate <2 mmol/L
                  • • Stable on low/no inotropes
                  • • Adequate MAP at reduced flow
                  • • Improving end-organ function
                  1. ✓

                     Outcome

                     Myocardial Recovery

                     Wean and decannulate

                  2. ◆

                     Decision

                     No Recovery - Bridge Options?

                     Consider advanced therapies

                     • Bridge to transplant (BTT)
                     • Bridge to durable LVAD
                     • Bridge to decision (BTD)
                     • Palliation/withdrawal if no options
         2. ●

            Action

            Impella (Percutaneous LVAD)

            For LV-predominant failure

            • INDICATIONS:
            • • Severe LV dysfunction, CI <1.8
            • • Need for LV unloading
            • • High-risk PCI support
            • DEVICES:
            • • CP: up to 4.3 L/min
            • • 5.0/5.5: up to 5+ L/min (surgical)
            • CONTRAINDICATIONS:
            • • Mechanical aortic valve
            • • LV thrombus
            • • Severe AS
            • • Severe PAD
         3. ●

            Action

            VA-ECMO / ECLS

            For biventricular or refractory failure

            • INDICATIONS:
            • • Biventricular failure
            • • Refractory cardiogenic shock
            • • Cardiac arrest (E-CPR)
            • • Failure of other devices
            • • Need for respiratory support
            • Provides 3-7 L/min full circulatory support
            • CONFIGURATION:
            • • Peripheral (femoral) or central cannulation
            • • Consider LV vent if no ejection
            1. ●

               Action

               LV Unloading Strategy

               Required if no LV ejection on VA-ECMO

               • Options:
               • • IABP (augments coronary flow)
               • • Impella (active LV drain)
               • • Surgical LV vent
               • • Atrial septostomy
               • Prevents LV distension and pulmonary edema
      2. ⚠

         Warning

         ⚠️ Rule Out First

         Before MCS, ensure: adequate surgical repair, no tamponade, no graft occlusion, no protamine reaction