Integrating Interventional

Cardiology and Heart

Failure Management for
Cardiogenic Shock
Navin K. Kapur, MDa,*, Carlos D. Davila, MDa,
Marwan F. Jumean, MDb

KEYWORDS
 Interventional heart failure  Mechanical circulatory support  Heart team  Cardiogenic shock

KEY POINTS
 Cardiogenic shock remains a major clinical problem with high rates of in-hospital mortality
that have not changed significantly over the past 3 decades.
 The primary objectives when managing cardiogenic shock include providing (1) circulatory
support, (2) ventricular unloading, and (3) coronary perfusion.
 The use of percutaneous acute mechanical circulatory support (AMCS) has steadily grown in
the last decade.
 Four primary AMCS device platforms are clinically available for hemodynamic support and
include (1) the intra-aortic balloon pump (IABP), (2) TandemHeart (TandemLife, Pittsburgh,
PA), (3) centrifugally driven venoarterial extracorporeal membrane oxygenation (VA-ECMO),
and (4) microaxial flow catheters (Impella, Abiomed, Danvers, MA).
 Interventional heart failure (IHF) is an emerging specialty within cardiology.

THE SPECTRUM OF ADVANCED HEART long-term outcomes among patients with acute
FAILURE AND CARDIOGENIC SHOCK myocardial infarction (AMI) complicated by
cardiogenic shock.4 For this reason, more pa-
Cardiogenic shock remains a major clinical prob- tients are surviving AMI and shock, which has
lem with high rates of in-hospital mortality that contributed to the growing population of pa-
have not changed significantly over the past 3 tients with advanced heart failure.5 Recent pro-
decades.1–3 One potential explanation for the jections estimated that more than 8 million
lack of progress in the management of cardio- individuals in the United States alone will be
genic shock is that the profile of patients diagnosed with heart failure.6 As a result, more
presenting with cardiogenic shock has changed. patients currently presenting with cardiogenic
In the late 1980s, the SHOCK trial (Should shock tend to be older, have more comorbid-
We Emergently Revascularize Occluded Coro- ities, and have preexisting cardiovascular dis-
naries for Cardiogenic Shock) highlighted the ease, including prior myocardial infarction or
beneficial impact of early revascularization on heart failure.7 This new complex profile of

Disclosure Statement: N.K. Kapur receives research support, consulting fees, and speaker honoraria from Abiomed Inc,
Maquet-Getinge Inc, St. Jude Inc, and Cardiac Assist Inc. He also receives NIH grant support (1R01HL133215-01). No
relevant disclosures for C.D. Davila and M.F. Jumean.
a
The Acute Mechanical Support Working Group, The Cardiovascular Center, Tufts Medical Center, 800 Washing-
ton Street, Boston, MA 02111, USA; b Center for Advanced Heart Failure, University of Texas Health Medical
School, 6400 Fannin Street, Houston, TX 77030, USA
* Corresponding author. The Cardiovascular Center, Tufts Medical Center, 800 Washington Street, Box # 80, Bos-
ton, MA 02111.
E-mail address: Nkapur@tuftsmedicalcenter.org

Intervent Cardiol Clin 6 (2017) 481–485

http://dx.doi.org/10.1016/j.iccl.2017.03.014
2211-7458/17/ª 2017 Elsevier Inc. All rights reserved.
482 Kapur et al

cardiogenic shock requires a more comprehen- harder. The net result is more myocardial oxygen
sive management approach that involves both consumption and potentially worse myocardial
interventional cardiologists and advanced heart ischemia. In contemporary clinical practice, the
failure cardiologists. 3 objectives of shock management can be
achieved using AMCS pumps.
CHANGING OBJECTIVES FOR THE
MANAGEMENT OF CARDIOGENIC SHOCK MECHANICAL CIRCULATORY SUPPORT:
INTERVENTIONAL TOOLS FOR COMPLEX
Three primary objectives when managing HEART FAILURE AND SHOCK
cardiogenic shock include providing (1) circula-
tory support, (2) ventricular unloading, and (3) In contrast to the IABP, the rotary flow pumps
coronary perfusion (Fig. 1). The sequence of that can achieve these objectives include both
achieving these 3 objectives must be tailored intracorporeal axial-flow (Impella, Abiomed)
to each patient. Although early revascularization and extracorporeal centrifugal flow (Tandem-
for cardiogenic shock secondary to AMI remains Heart, TandemLife) pumps that can directly
an important therapeutic objective, a recent reduce ventricular filling pressures while
analysis of patients with ST segment elevation increasing mean arterial pressure within minutes
myocardial infarction (STEMI) failed to identify of activation.9 The TandemHeart left ventricular
any incremental reduction in in-hospital mortal- (LV) support pump requires a trans-septal punc-
ity with door-to-balloon reperfusion times less ture and diverts blood from the left atrium to the
than 90 minutes.8 These data suggest that timely femoral artery using 2 large-bore cannulas. The
coronary reperfusion alone may be insufficient to Impella pump is a transvalvular pump that di-
reduce mortality associated with cardiogenic verts blood from the left ventricle to the aorta.
shock and that other therapeutic objectives In contrast to the TandemHeart LV pump, the
may take priority depending on the clinical sce- Impella series of pumps can be implanted via
nario. For example, a patient with profound the femoral, brachial, or axillary approach. Ac-
hypoperfusion due to low cardiac output in the cess via the brachial or axillary approach allows
setting STEMI may not benefit from immediate for increased patient mobility, which becomes
coronary reperfusion but instead may require critically important when managing patients in
stabilization of their mean arterial pressure (cir- shock awaiting myocardial recovery, a decision
culatory support) and a reduction in cardiac to advanced therapies, or palliation. Under
filling pressures before reperfusion. Typically, emergent conditions, both the Impella and Tan-
physicians start vasopressors and inotropes, demHeart devices may be deployed quickly;
which may partially achieve these objectives however, emergent trans-septal puncture is not
but at the cost of reducing end-organ microvas- commonly performed in most centers. VA-
cular perfusion and forcing the heart to work ECMO is another support option that pumps

Fig. 1. Illustration of the acute he-

modynamic support equation. Cir-
culatory support is defined by an
increase in mean arterial pressure.
Ventricular support is defined by
a reduction in LV pressure and vol-
ume, thereby reducing myocardial
wall stress and oxygen demand.
Coronary perfusion is defined by
an increase in the transmyocardial
gradient, which is determined by
the difference between coronary
arterial and LV end-diastolic pres-
sure. The net effect of optimal he-
modynamic support is increased
urine output, reduced serum
lactate, reduced pulmonary capil-
lary wedge pressure, resolution of
ischemic electrocardiographic changes, and reduced levels of myocardial injury biomarkers, such as creatine ki-
nase–MB. An ideal mechanical circulatory support device would target all elements of the hemodynamic equation
and prove safe and easy to use in the acute setting. Ao, aortic; BNP, brain natriuretic peptide; CK-MB, Creatine
Kinase-MB; EDP, end-diastolic pressure; ESP, end-systolic pressure; MAP, mean arterial pressure.
 Heart Team Management for Shock 483

and oxygenates blood from the venous to arte-

rial circulation. In contrast to the Impella and
TandemHeart devices that directly unload the
left-sided circulation, VA-ECMO indirectly un-
loads the LV if a large enough venous drainage
cannula is placed; otherwise, a concomitant use
of an LV unloading device may be required.10,11
For this use, Impella seems more beneficial than
IABP. Although none of these 3 AMCS is
complication-free, all can rapidly achieve the 3
primary objective of cardiogenic shock in the
setting of STEMI with profound systemic hypo-
perfusion due to low cardiac output. Recent
data support that first providing circulatory and
ventricular support before coronary reperfusion
reduces short-term mortality among patients
with STEMI and shock.12 Fig. 2. Components of a cardiogenic shock team.

THE HEART TEAM: AN EVOLVING approach allows for reversal of underlying causes
MULTISPECIALTY COLLABORATION of shock and early implementation of AMCS in
cardiogenic shock when necessary. The role of
Over the past 2 decades, growth in 3 major cardiac the cardiac surgeon on the heart team is to
device domains helped to shape contemporary manage post-MI mechanical complications and
practice around cardiogenic shock. The REMATCH surgical coronary revascularization if PCI is not
trial (Randomized Evaluation of Mechanical Assis- an option, to assist with initiation of AMCS or
tance for the Treatment of Congestive Heart Fail- VA-ECMO, and to provide input regarding candi-
ure) in 2001 showed a reduction of 48% in the risk dacy for LVAD or orthotopic heart transplantation
of death in advanced heart failure patients (OHTx). The advanced heart failure specialist also
receiving pulsatile left ventricular assist device assists with evaluating a patient’s candidacy for
(LVAD) therapy compared with optimal medical LVAD or OHTx, hemodynamic optimization, and
therapy.13 A landmark study identified that the management of AMCS or VA-ECMO and pro-
Heartmate II (Thoratec, Pleasanton, CA) rotary vides input regarding end-of-life decision
flow LVAD demonstrated superior clinical out- making, palliation, and medical futility. Finally,
comes compared with pulsatile LVADs for patients the role of the cardiac intensivist is a critically
with advanced heart failure.14 This trial triggered important component of a successful cardiogenic
immense growth in the use of LVADs. Around the shock program. In addition to assisting with
same time, AMCS device use within the interven- hemodynamic optimization and AMCS device
tional cardiology community was growing for management, the intensivist provides key input
high-risk percutaneous coronary intervention and on the management of noncardiac organ sys-
for cardiogenic shock.15,16 Third, the growing use tems, including pulmonary, renal, hepatic, and
of percutaneous aortic valve replacement pro- hematologic abnormalities as well as prevention
grams supported the ongoing cross-talk between and management of infectious issues. Further-
cardiac surgery, interventional cardiology, and more, intensivists provide input on nutrition, early
advanced heart failure specialists. This unique mobilization, and prophylaxis against deep
collaboration, commonly known as the heart venous thrombosis, gastric ulcers, and cutaneous
team approach, is now applied to patients with ulcers. Recent data support that incorporation of
cardiogenic shock and includes a growing role for a cardiac intensivist improves short and long-term
cardiac intensive care specialists (Fig. 2). mortality for cardiogenic shock.17
Communication and teamwork among these 4
core groups are fundamental to optimizing clin- BEYOND SHOCK: THE EXPANDING ROLE
ical outcomes in cardiogenic shock. Depending OF INTERVENTIONAL CARDIOLOGY
on the clinical scenario, the role of each of these
4 components may change. The role of the Similar to the expansion in armamentarium of
interventional cardiologist on the heart team is AMCS in acute and chronic heart failure over the
to provide coronary revascularization, invasive past decade, a similar trend has happened in
hemodynamic assessment, and then AMCS for structural interventions for this increasing
LV, right ventricular, or biventricular failure. This patient population. The use of MitraClip (Abbott,
484 Kapur et al

Chicago, IL) for symptomatic functional mitral interventional cardiology and advanced heart
regurgitation,18 TAVR for low-flow severe aortic failure. Graduates of IHF training programs
stenosis,19 percutaneous ventricular restoration should seek interventional positions within a
therapy with Parachute device (Cardiokinetix, team-based structure for management of
Menlo Park, CA) for dilated cardiomyopathy,20 advanced heart failure patients.
and outflow graft stenting for LVAD outflow graft If the answer to that fundamental question is
stenosis21 are therapies currently being evaluated advanced heart failure, then IHF training may
in clinical studies that require a heart team not be the right path to pursue. Most fellows
approach to decision-making with the interven- whose primary interest is advanced heart failure
tionalist and heart failure cardiologist at its core. wish to pursue interventional training to gain
skills for device implantation. Implanting AMCS
INTERVENTIONAL HEART FAILURE devices is not a reason, however, to pursue inter-
TRAINING: IS THIS RIGHT FOR ME? ventional cardiology training. Without a strong
commitment to interventional cardiology as a
Contemporary training programs focus on devel- clinical practice, IHF training only serves to
oping 1 of the 4 specialists required for the heart develop substandard operators who do not
team. As understanding of hemodynamics, meta- routinely perform cardiac interventions but
bolic failure, and the importance of early initiation rather intermittently are exposed to the cathe-
of AMCS devices grows, training programs will terization laboratory. For those fellows inter-
need to adapt. Although many interventionalists ested primarily in advanced heart failure, new
may be comfortable with AMCS device implanta- programs, such as the Training and Education
tion and invasive hemodynamic catheter place- in Advanced Cardiovascular Hemodynamics
ment, decision making around AMCS device (TEACH) program provide an in-depth under-
management, patient candidacy, and a viable standing of advanced hemodynamics in heart
exit strategy (that is, recovery, LVAD therapy, or failure and shock as well as a deep understand-
OHTx candidacy) or the role of pharmacologic ing of mechanical support device management.
therapy for advanced heart failure and shock is Over the next decade, understanding of
not part of the typical interventional training curric- acute and chronic heart failure device manage-
ulum. Advanced heart failure fellowship offers the ment will change immensely. This change will
reciprocal training experience with no exposure to be driven by growth in the number of patients
implantation of AMCS devices or advanced with heart failure, increasing patient complexity,
hemodynamics in the catheterization laboratory. and new diagnostic and therapeutic options for
Furthermore, formal training in cardiac intensive these patients. With appropriate training, collab-
care is often lacking in most cardiology training oration among each of the 4 physician compo-
programs. As a result, fellows in training are begin- nents of the heart team will ultimately lead to
ning to seek programs where they can complete better patient outcomes.
combined advanced training in interventional car-
diology, heart failure, or critical care. REFERENCES
Fellows considering training in both interven-
tional cardiology and advanced heart failure, 1. Goldberg RJ, Gore JM, Thompson CA, et al.
however, must ask themselves a fundamental Recent magnitude of and temporal trends (1994-
question, “If you had to choose one pathway, 1997) in the incidence and hospital death rates of
which would it be — interventional cardiology cardiogenic shock complicating acute myocardial
or advanced heart failure?” If the answer is inter- infarction: the second national registry of myocar-
ventional cardiology, then IHF training may be dial infarction. Am Heart J 2001;141(1):65–72.
the right path to pursue.22 IHF training allows 2. Goldberg RJ, Samad NA, Yarzebski J, et al. Tem-
trainees to technically function as interventional poral trends in cardiogenic shock complicating
operators with the ability to handle vascular, acute myocardial infarction. N Engl J Med 1999;
coronary, ventricular, and basic structural inter- 340(15):1162–8.
ventions, while at the same time acquiring the 3. Wayangankar SA, Bangalore S, McCoy LA, et al.
cognitive skills to understand the fundamentals Temporal trends and outcomes of patients under-
of heart failure physiology and advanced heart going percutaneous coronary interventions for
failure decision making. This 2-year program cardiogenic shock in the setting of acute myocar-
optimally begins with advanced heart failure dial infarction: a report from the CathPCI Registry.
training for months 1 to 12 and ends with JACC Cardiovasc Interv 2016;9(4):341–51.
interventional training in months 13 to 24. IHF 4. Hochman JS, Sleeper LA, Webb JG, et al. Early
graduates should be board-eligible in both revascularization in acute myocardial infarction
 Heart Team Management for Shock 485

complicated by cardiogenic shock. SHOCK Investi- 13. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term
gators. Should we emergently revascularize use of a left ventricular assist device for end-stage
occluded coronaries for cardiogenic shock. heart failure. N Engl J Med 2001;345(20):1435–43.
N Engl J Med 1999;341(9):625–34. 14. Slaughter MS, Rogers JG, Milano CA, et al.
5. Ezekowitz JA, Armstrong PW, Granger CB, et al. Advanced heart failure treated with continuous-
Predicting chronic left ventricular dysfunction 90 flow left ventricular assist device. N Engl J Med
days after ST-segment elevation myocardial infarc- 2009;361(23):2241–51.
tion: An Assessment of Pexelizumab in Acute 15. Stretch R, Sauer CM, Yuh DD, et al. National trends
Myocardial Infarction (APEX-AMI) Substudy. Am in the utilization of short-term mechanical circula-
Heart J 2010;160(2):272–8. tory support: incidence, outcomes, and cost anal-
6. Hunt SA, Abraham WT, Chin MH, et al. 2009 ysis. J Am Coll Cardiol 2014;64(14):1407–15.
focused update incorporated into the ACC/ 16. Sandhu A, McCoy LA, Negi SI, et al. Use of me-
AHA 2005 guidelines for the diagnosis and chanical circulatory support in patients undergoing
management of heart failure in adults: a report percutaneous coronary intervention: insights from
of the American College of Cardiology Founda- the National Cardiovascular Data Registry. Circula-
tion/American Heart Association Task Force on tion 2015;132(13):1243–51.
Practice Guidelines: developed in collaboration 17. Na SJ, Chung CR, Jeon K, et al. Association be-
with the International Society for Heart and tween presence of a cardiac intensivist and mortal-
Lung Transplantation. Circulation 2009;119(14): ity in an adult cardiac care unit. J Am Coll Cardiol
e391–479. 2016;68(24):2637–48.
7. Ezekowitz JA, Kaul P, Bakal JA, et al. Declining in- 18. Stone G, Abraham W, Lindenfeld J, et al. TCT-627
hospital mortality and increasing heart failure inci- Cardiovascular Outcomes Assessment of MitraClip
dence in elderly patients with first myocardial Therapy in Heart Failure Patients with Functional
infarction. J Am Coll Cardiol 2009;53(1):13–20. Mitral Regurgitation (The COAPT Trial): baseline
8. Menees DS, Peterson ED, Wang Y, et al. Door- characteristics and preliminary 30-day and 1-year
to-balloon time and mortality among patients outcomes of the roll-in cohort. J Am Coll Cardiol
undergoing primary PCI. N Engl J Med 2013; 2016;68(18S):B255.
369(10):901–9. 19. Martinez CA, Singh V, Heldman AW, et al. Emergent
9. Morine KJ, Kapur NK. Percutaneous mechanical cir- use of retrograde left ventricular support in patients
culatory support for cardiogenic shock. Curr Treat after transcatheter aortic valve replacement. Cath-
Options Cardiovasc Med 2016;18(1):6. eter Cardiovasc Interv 2013;82(2):E128–32.
10. Aghili N, Kang S, Kapur NK. The fundamentals of 20. Costa MA, Mazzaferri EL Jr, Sievert H, et al. Percu-
extra-corporeal membrane oxygenation. Minerva taneous ventricular restoration using the parachute
Cardioangiol 2015;63(1):75–85. device in patients with ischemic heart failure: three-
11. Kapur NK, Zisa DC. Veno-arterial extracorporeal year outcomes of the PARACHUTE first-in-human
membrane oxygenation (VA-ECMO) fails to study. Circ Heart Fail 2014;7(5):752–8.
solve the haemodynamic support equation in 21. Pham DT, Kapur NK, Dermody M, et al. Stenting of
cardiogenic shock. EuroIntervention 2016;11(12): an outflow graft obstruction after implantation of a
1337–9. continuous-flow, axial-flow left ventricular assist de-
12. O’Neill WW, Schreiber T, Wohns DH, et al. The cur- vice. J Thorac Cardiovasc Surg 2015;150(1):e11–2.
rent use of Impella 2.5 in acute myocardial infarc- 22. Kapur NK, Dimas V, Sorajja P, et al. The Interven-
tion complicated by cardiogenic shock: results tional Heart Failure Initiative: a mission statement
from the USpella Registry. J Interv Cardiol 2014; for the next generation of invasive cardiologists.
27(1):1–11. Catheter Cardiovasc Interv 2015;86(2):353–5.