Mechanical circulatory support: IABP, Impella, and ECMO for cardiogenic shock

Also known as IABP · Intra-aortic balloon pump · Impella · VA-ECMO · TandemHeart · Mechanical circulatory support · MCS

Mechanical circulatory support (MCS) for refractory cardiogenic shock spans a spectrum from modest afterload reduction to full cardiopulmonary replacement. (1) IABP (intra-aortic balloon pump): counterpulsation in the descending thoracic aorta — inflates in diastole (augmenting coronary perfusion), deflates at systole (reducing afterload); modest support (~0.5-1.0 L/min augmentation). IABP-SHOCK II (Thiele 2012, NEJM): NO mortality benefit in AMI-CS — routine use not recommended. (2) Impella: transaortic axial-flow micro-pump actively unloading the LV (Impella CP 2.5-4.0 L/min; Impella 5.0/5.5 up to 5.5 L/min). DanGer-SHOCK (Moller 2024, NEJM): IMPROVED 180-day survival in AMI-CS (45.8% vs 58.5% deaths). IMPRESS (Ouweneel 2017): no benefit in severe shock. (3) VA-ECMO (venoarterial ECMO): full cardiopulmonary bypass, 4-6 L/min + oxygenation; peripheral (femoro-femoral) vs central (ascending aorta); requires distal perfusion cannula and often LV venting. ECLS-SHOCK (Thiele 2023, NEJM): no mortality benefit at 30 days. (4) TandemHeart (LA-to-femoral arterial centrifugal pump, ~4 L/min) and ProtekDuo (dual-lumen RA-to-PA cannula for RV support). SCAI shock stages A-E guide escalation. Complications: bleeding (anticoagulation), thrombosis, limb ischaemia, haemolysis, infection, stroke, LV distension (VA-ECMO), Harlequin syndrome.

high18 referencesUpdated 26 July 202621 min readVerification in progress

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8 MCQs

Meet the patient

A 68-year-old man, six hours after an anterior STEMI complicated by an out-of-hospital arrest. Primary PCI to the proximal LAD was technically successful. On ICU arrival he is intubated and sedated, hypotensive on an escalating noradrenaline infusion, with a rising lactate and falling urine output. A new loud pansystolic murmur at the apex. Focused echo: a flail segment of the anterior mitral leaflet with severe MR, a moderately reduced LVEF, and no aortic regurgitation. Mechanical complications of MI such as papillary muscle rupture most commonly declare themselves within the first week after the infarct, present as cardiogenic shock or acute pulmonary oedema, and are usually first identified — with their type, location, and haemodynamic consequences — by echocardiography.^[14]

The team wants an IABP. The question that decides the device is the question that decides every MCS case: what is failing, and what is reversible? This man has a mechanical complication of MI (papillary muscle rupture) in SCAI stage D shock — an IABP as a bridge to surgery is exactly right. But reach for the wrong device — VA-ECMO in isolated LV failure, or an IABP in profound biventricular failure — and you have added complications without support patient needs.^[1]^[6]

References18Show

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[2]Thiele H, Zeymer U, Thelemann N, et al. Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction: Long-Term 6-Year Outcome of the Randomized IABP-SHOCK II Trial Circulation, 2019.PMID 30586721
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