7.2 Circulatory Support for Cardiogenic Shock: Matching the Device Strategy to the Patient for Best Outcomes

Problem Presenter: Mike Rinaldi

These proceedings summarize the educational activity of the 18th Biennial Meeting of the International Andreas Gruentzig Society held January 27 to 30, 2026, in Puerto Ayora, Santa Cruz, Ecuador.

Faculty Disclosures     Sponsors

2026 IAGS Summary Document

Statement of problem or issue

Cardiogenic shock (CS) is a life-threatening condition characterized by severe circulatory failure with insufficient cardiac output and end-organ hypoperfusion. Short-term mortality ranges from 30% to 40% and 1-year mortality approaches or exceeds 50%.[1] General principles governing the management of patients with CS due to heart failure (HF) or myocardial infarction (AMI) are listed below:

• The cornerstone of CS care is right-heart catheterization (RHC).
  • RHC has been associated with mortality benefit.
• Congestion kills
  • More strongly associated with mortality than the cardiac index
  • Support devices must allow for both perfusion and decongestion
• Management of CS centers on assessment of:
  • Severity of shock (SCAI-CSWG class)
  • Hemodynamic phenotype (LV, RV, Bi-V, HF-CS)
  • Acuity (acute versus chronic)
  • Hemodynamic and hemo-metabolic response to therapies

One useful algorithm for assessing CS patients and choosing mechanical circulatory support (MCS) devices can be found in the Scientific Statement from the American Heart Association (Geller BJ, et al. Circulation. 2022;146(6):e50-e68). [2]

It is important to realize that MCS devices are not magic. They are not resurrection tools. Critical decisions about when and how to put them on, how to manage them, how to take them off quickly, and then what to do after that, are just as important as having any of them available. A de-escalation plan is just as important as an initiation plan. One example of a set of weaning strategies can be found in the AHA statement. [2]

Average MCS support times are typically 3-to-5 days, although a microflow pump (Impella) placed via axillary access can remain much longer, even for weeks or more. Patients who fail may need an implantable ventricular assist device (RVAD/LVAD), an orthotopic heart transplant, or palliative/hospice care.

Gaps in current knowledge

There is one randomized trial of an MCS device in patients with AMI-CS, and it showed a mortality benefit.[3] A randomized trial of MCS in patients with HF-CS showed no benefit.[4] However, it is important to recognize: (1) HF-CS is more heterogeneous that AMI-CS, (2) early initiation and appropriate patient selection are critical, (3) stabilization on MCS is only temporary and allows for decongestion and other interventions to change the course of the underlying problem, and thereby bridge the patient to further definitive therapy. How to efficiently and effectively organize these principles for HF-CS patients is a knowledge gap area. Furthermore, identifying which HF-CS patients might benefit the most from MCS, and which ones do not benefit at all, is also a gap area.

Reducing complications is an important area where some data are available, but much more needs to be done. Some current strategies to reduce complications, and which need refinement, are listed below:

• Bivalirudin is superior to heparin for anticoagulation in ECMO; reduces HIT.
• Arterial access with ultrasound guidance and micropuncture needles.
• No arterial cannulas >17F.
• Pre-close access sites.
• Universal antegrade perfusion sheath reduces limb ischemia.
• Early support before hepatic injury causes coagulopathy.
• Brief support times: initiate early, manage aggressively, reassess frequently, terminate ASAP.

Possible solutions or future directions

We will need to determine how MCS devices and care management protocols can be fitted together into a comprehensive “system of care.” It is likely that clinical benefits reside in the care team and not in any device. To examine this question, we need to design clinical trials able to test the “system of care” hypothesis, and this may not be easy.

Encouraging early RHC and interpretation of clinical and hemodynamic data according to SCAI shock classification categories, along with frequent patient reevaluation, must be undertaken. Industry sponsored education programs and artificial intelligence (AI) based data analyses likely will help.

Another avenue for future direction will be to determine if a “hub-and-spoke” system can be designed. Smaller, regional hospitals might then be able to initiate MCS support and transfer patients to larger, central hospitals.

References

1. Sinha SS, et al. 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Evaluation and Management of Cardiogenic Shock: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2025;85(16):1618-1641. doi: 10.1016/j.jacc.2025.02.018. Epub 2025 Mar 17. PMID: 40100174.
2. Geller BJ, et al. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2022;146(6):e50-e68. doi: 10.1161/CIR.0000000000001076. Epub 2022 Jul 7. PMID: 35862152.
3. Møller JE, et al; DanGer Shock Investigators. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med. 2024;390(15):1382-1393. doi: 10.1056/NEJMoa2312572. Epub 2024 Apr 7. PMID: 38587239.
4. Ostadal P, et al; ECMO-CS Investigators. Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial. Circulation. 2023;147(6):454-464. doi: 10.1161/CIRCULATIONAHA.122.062949. Epub 2022 Nov 6. PMID: 36335478.