Postcardiotomy Cardiogenic Shock
Failure to wean from CPB or post-op hemodynamic deterioration
All Pathways
Cardiothoracic SurgeryManagement
Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025)
Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025): Postcardiotomy Cardiogenic Shock → Initial Assessment → Shock Severity? → IABP (Intra-Ao...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Action 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
03Decision 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
04Action 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
05Action 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)
06Decision 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
07Outcome Myocardial Recovery
Wean and decannulate
08Decision No Recovery - Bridge Options?
Consider advanced therapies
- Bridge to transplant (BTT)
- Bridge to durable LVAD
- Bridge to decision (BTD)
- Palliation/withdrawal if no options
09Action 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
- Path rejoins step 05Shared downstream outcome
10Action 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
11Action 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
- Path rejoins step 05Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
12Warning ⚠️ Rule Out First
Before MCS, ensure: adequate surgical repair, no tamponade, no graft occlusion, no protamine reaction
Guideline Source
EACTS/STS/AATS Guidelines on Temporary MCS in Adult Cardiac Surgery
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Device availability varies by institution
- Requires specialized team for insertion and management
- Specific device selection depends on local expertise
- Does not replace clinical judgment for complex cases
Applicable Regions
USEU
Version 1Next review: 2027-01-11
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025)?
The Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025) is a management clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on EACTS/STS/AATS Guidelines on Temporary MCS in Adult Cardiac Surgery.
What guideline is the Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025) based on?
This algorithm is based on EACTS/STS/AATS Guidelines on Temporary MCS in Adult Cardiac Surgery (DOI: 10.1093/ejcts/ezaf330).
What are the limitations of the Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025)?
Known limitations include: Device availability varies by institution; Requires specialized team for insertion and management; Specific device selection depends on local expertise; Does not replace clinical judgment for complex cases. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Temporary Mechanical Circulatory Support (EACTS/STS/AATS 2025) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free