Current Landscape for Use of Mechanical Circulatory Support Devices (Podcast)

When a patient at Cleveland Clinic is in cardiogenic shock or has significant ventricular dysfunction, the health system’s Heart, Vascular and Thoracic Institute convenes a “shock call” within minutes. The call gathers a multidisciplinary team — cardiac surgeons, cardiologists, ICU physicians, anesthesiologists, nurse and others — to assess the patient’s case and collectively decide on the best treatment strategy.

The strategy often includes some form of temporary mechanical circulatory support (MCS), typically either the Impella 5.5^® microaxial temporary left ventricular assist device or extracorporeal membrane oxygenation (ECMO). Implantation of these devices can swiftly be done on a 24/7 basis in the operating room, in a catheterization lab or at the bedside in an ICU.

In a new episode of Cleveland Clinic’s Cardiac Consult podcast, two Cleveland Clinic experts in MCS use — Amar Krishnaswamy, MD, Section Head of Invasive and Interventional Cardiology, and Edward Soltesz, MD, MPH, Surgical Director of the Kaufman Center for Heart Failure Treatment and Recovery — discuss contemporary use of MCS devices, touching on the following:

• Use in myocardial infarction patients
• Tailored use of MCS in cardiogenic shock management
• Importance of a multidisciplinary team for optimal MCS benefit
• ECPella, or the combined use of ECMO and Impella
• Use of temporary MCS for ventricular support to enable surgery in patients with weak heart function
• ECMO in select cardiac arrest cases

Click the podcast player above to listen to the 16-minute episode now, or read on for an edited excerpt. Check out more Cardiac Consult episodes at clevelandclinic.org/cardiacconsultpodcast or wherever you get your podcasts.

Excerpt from the podcast

Amar Krishaswamy, MD: In the contemporary era, we provide a lot of care for cardiac patients through catheter-based strategies. However, there are a number of patients, especially that we see at Cleveland Clinic, who just can’t be treated effectively with a catheter, whether they need multivessel coronary bypass grafting or have complex valvular heart disease. Unfortunately, on top of those diseases, they have a very weak heart. Traditionally, and in other institutions, these patients might not be offered cardiac surgery. But you and your group have been able to take many of these patients through surgery successfully using things like an Impella as a support device to nurse the patient through that perioperative and postoperative time. Can you speak to that application of mechanical circulatory support?

Ed Soltesz, MD, MPH: A lot of heart surgery in the United States is performed in patients with poor ventricular function, as you noted. Unfortunately, a lot of patients are denied lifesaving heart surgery or catheter-based procedures because of low heart function. What we’ve come to realize is that we can provide temporary circulatory support, most commonly with the Impella device, but sometimes with a combination of other devices as well, to bridge patients through the initial period, usually 48 to 72 hours after surgery or a procedure, where their heart function is really compromised because of the intervention and we’re waiting for the recovery period. This is a way we’ve been able to offer lifesaving surgery to patients who otherwise would be denied that opportunity because their heart function has been too low.

If we can get them through that time that’s the most challenging in the immediate postoperative period, it turns out they are then able to benefit from what we’ve done for them surgically, whether it be bypass surgery or valve surgery.