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Acute Myocardial Infarction With Cardiogenic Shock: - Navigating the Invasive Options in Clinical Management

2021; Elsevier BV; Volume: 35; Issue: 11 Linguagem: Inglês

10.1053/j.jvca.2021.07.014

1532-8422

Jesse Kiefer, John Augoustides,

Cardiac Arrest and Resuscitation

A MULTIDISCIPLINARY working group from the American Heart Association recently published a perspective about the mechanical circulatory support options for acute myocardial infarction complicated by cardiogenic shock.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar This scientific statement has high impact given the complex patient population addressed, the noted variability in practice across regions, and the inherent value of this topic.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar,2Shah RU de Lemos JA Wang TY et al.Post-hospital outcomes of patients with acute myocardial infarction with cardiogenic shock: Findings from the NCDR.J Am Coll Cardiol. 2016; 67: 739-747Crossref PubMed Scopus (64) Google Scholar Cardiogenic shock is a common cause for mortality in patients with acute myocardial infarction, not only during the acute phase but up to one year from hospital discharge, representing a contrast to the improved outcomes for acute myocardial infarction without cardiogenic shock.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar,2Shah RU de Lemos JA Wang TY et al.Post-hospital outcomes of patients with acute myocardial infarction with cardiogenic shock: Findings from the NCDR.J Am Coll Cardiol. 2016; 67: 739-747Crossref PubMed Scopus (64) Google Scholar Although multiple clinical challenges remain, this clinical perspective serves a dual purpose first as a foundation for clinical management and second as a resource to guide future research in this complex landscape.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar,2Shah RU de Lemos JA Wang TY et al.Post-hospital outcomes of patients with acute myocardial infarction with cardiogenic shock: Findings from the NCDR.J Am Coll Cardiol. 2016; 67: 739-747Crossref PubMed Scopus (64) Google Scholar In this editorial, the authors discuss the background and key components of this scientific statement to highlight the relevance for practice within the field of cardiothoracic anesthesiology and critical care. For the continued success and growth of this specialty, it is paramount that there is familiarity with these clinical innovations because they impact patients in perioperative environments such as the cardiac catheterization laboratory, the operating room, and/or the intensive care unit. The benefits of early coronary revascularization in acute myocardial infarction with cardiogenic shock were demonstrated in the original SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial.3Hochman JS Sleeper LA Webb JG et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2135) Google Scholar Early coronary revascularization in this setting significantly improved survival at six months and one year, but not at 30 days.3Hochman JS Sleeper LA Webb JG et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2135) Google Scholar, 4Hochman JS Sleeper LA White HD et al.One-year survival following early revascularization for cardiogenic shock.JAMA. 2001; 285: 190-192Crossref PubMed Scopus (541) Google Scholar A consistent survival benefit favoring early revascularization prompted the American Heart Association in 2013 to propose targets for timely intervention in this clinical emergency of 90-to-120 minutes from first medical contact, depending on the percutaneous intervention capabilities of the given hospital.5O'Gara PT Kushner FG Ascheim DD et al.ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 61: 485-510Crossref PubMed Scopus (471) Google Scholar Further support for these recommendations has come from a contemporary analysis that highlighted the risks of delayed revascularization in acute myocardial infarction patients with cardiogenic shock.6Kochar A HR Al-Khalidi Hansen SM et al.Delays in primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients presenting with cardiogenic shock.JACC Cardiovasc Interv. 2018; 11: 1824-1833Crossref PubMed Scopus (24) Google Scholar This detailed analysis of a large clinical registry demonstrated that coronary intervention within 90 minutes significantly reduced mortality (20.5% compared with 39.1%: p < 0.001).6Kochar A HR Al-Khalidi Hansen SM et al.Delays in primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients presenting with cardiogenic shock.JACC Cardiovasc Interv. 2018; 11: 1824-1833Crossref PubMed Scopus (24) Google Scholar This trial also emphasized the imperative for organized regional management protocols, as fewer than 40% of patient interventions fell within the specified time targets for this challenging clinical scenario.6Kochar A HR Al-Khalidi Hansen SM et al.Delays in primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients presenting with cardiogenic shock.JACC Cardiovasc Interv. 2018; 11: 1824-1833Crossref PubMed Scopus (24) Google Scholar What are the important steps for successful management of acute myocardial infarction presenting with cardiogenic shock? The five key ingredients have been outlined as follows: early diagnosis, initial stabilization and diagnostic evaluation, revascularization of the culprit lesion, judicious mechanical circulatory support, and expert in-hospital management.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar,7Brilakis ES Eckman P. The five key "ingredients" for improving outcomes in cardiogenic shock complicating acute myocardial infarction.Catheter Cardiovasc Interv. 2018; 91: 462-463Crossref PubMed Scopus (3) Google Scholar This clinical pentad was derived from the Detroit cardiogenic shock initiative that evaluated the feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock.7Brilakis ES Eckman P. The five key "ingredients" for improving outcomes in cardiogenic shock complicating acute myocardial infarction.Catheter Cardiovasc Interv. 2018; 91: 462-463Crossref PubMed Scopus (3) Google Scholar,8Basir MB Schreiber T Dixon S et al.Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.Catheter Cardiovasc Interv. 2018; 91: 454-461Crossref PubMed Scopus (131) Google Scholar This Detroit initiative protocolized clinical care to emphasize the early adoption of mechanical circulatory support across multiple metropolitan areas to demonstrate both the feasibility of dedicated shock protocols with early mechanical circulatory support and the potential for improved survival.8Basir MB Schreiber T Dixon S et al.Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.Catheter Cardiovasc Interv. 2018; 91: 454-461Crossref PubMed Scopus (131) Google Scholar This trial demonstrated an 85% survival to weaning from mechanical circulatory support and a 76% survival to hospital discharge rate.8Basir MB Schreiber T Dixon S et al.Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.Catheter Cardiovasc Interv. 2018; 91: 454-461Crossref PubMed Scopus (131) Google Scholar It is notable that before the initiation of this protocolized approach, the survival rate to discontinuation of mechanical circulatory support was 51%.8Basir MB Schreiber T Dixon S et al.Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.Catheter Cardiovasc Interv. 2018; 91: 454-461Crossref PubMed Scopus (131) Google Scholar Across the United States and internationally, there is a growing adoption of regional shock centers for the streamlined and integrated evaluation and management of cardiogenic shock.7Brilakis ES Eckman P. The five key "ingredients" for improving outcomes in cardiogenic shock complicating acute myocardial infarction.Catheter Cardiovasc Interv. 2018; 91: 462-463Crossref PubMed Scopus (3) Google Scholar, 8Basir MB Schreiber T Dixon S et al.Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.Catheter Cardiovasc Interv. 2018; 91: 454-461Crossref PubMed Scopus (131) Google Scholar, 9Tehrani B Truesdell A Singh R et al.Implementation of a cardiogenic shock team and clinical outcomes (INOVA-SHOCK Registry): Observational and retrospective study.JMIR Res Protoc. 2018; 7: e160Crossref PubMed Scopus (19) Google Scholar The suggested management framework from the American Heart Association includes the following six considerations: assessment and classification of shock, stabilization, diagnosis for cause of shock, consideration of early mechanical circulatory support, revascularization of culprit lesion, and transfer to intensive care.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar In this clinical approach, the diagnosis and classification of shock frame the subsequent steps, such as choice of therapies and discussion of prognosis.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar Although there is agreement surrounding the diagnosis of an acute myocardial infarction, the diagnosis of cardiogenic shock has required further clarification due to its phenotypic spectrum. Is shock defined by bedside examination, blood pressure, cardiac output, markers of end-organ injury, need for vasoactive or mechanical support, or a constellation of these? A patient may appear "unwell" but may not formally meet one of the existing definitions. The Society for Cardiovascular Angiography and Intervention has developed a five-tiered classification model for defining cardiogenic shock according to a patient's clinical findings, biochemical markers, and hemodynamic state (refer to Table 1).10Baran DA Grines CL Bailey S et al.SCAI clinical expert consensus statement on the classification of cardiogenic shock.Catheter Cardiovasc Interv. 2019; 94: 29-37PubMed Google Scholar This progressive definition of cardiogenic shock covers its full clinical spectrum in an effort to remove this heterogeneity surrounding this important diagnosis.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar The impact familiarity of these five classes of cardiogenic shock will only grow in importance as these classes achieve widespread adoption.10Baran DA Grines CL Bailey S et al.SCAI clinical expert consensus statement on the classification of cardiogenic shock.Catheter Cardiovasc Interv. 2019; 94: 29-37PubMed Google Scholar,11Schrage B Dabboura S Yan I et al.Application of the SCAI classification in a cohort of patients with cardiogenic shock.Catheter Cardiovasc Interv. 2020; 96: E213-E219Crossref PubMed Scopus (56) Google Scholar Schrage et al. correlated 30-day mortality to these tiers of cardiogenic shock in 1,007 patients to find that survival was significantly lower in advancing tiers of cardiogenic shock (p < 0. 01).11Schrage B Dabboura S Yan I et al.Application of the SCAI classification in a cohort of patients with cardiogenic shock.Catheter Cardiovasc Interv. 2020; 96: E213-E219Crossref PubMed Scopus (56) Google Scholar Specifically, these investigators demonstrated the survival probability was 96.4% (95% confidence interval 93.7-99.0%) in class A, 66.1% (95% confidence interval 50.2-87.1%) in class B, 46.1% (95% confidence interval 40.6-52.4%) in class C, 33.1% (95% confidence interval 26.6-41.1%) in class D, and 22.6% (95% confidence interval 17.1-30.0%) in class E (Table 1).11Schrage B Dabboura S Yan I et al.Application of the SCAI classification in a cohort of patients with cardiogenic shock.Catheter Cardiovasc Interv. 2020; 96: E213-E219Crossref PubMed Scopus (56) Google Scholar These findings suggested that mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock could provide early benefit in classes A and B, stabilization in class C, and potential salvage in classes D and E.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar,10Baran DA Grines CL Bailey S et al.SCAI clinical expert consensus statement on the classification of cardiogenic shock.Catheter Cardiovasc Interv. 2019; 94: 29-37PubMed Google Scholar,11Schrage B Dabboura S Yan I et al.Application of the SCAI classification in a cohort of patients with cardiogenic shock.Catheter Cardiovasc Interv. 2020; 96: E213-E219Crossref PubMed Scopus (56) Google Scholar The clinical utility of this classification includes a multidisciplinary approach to this clinical emergency, with enhanced communication across the participating subspecialties.Table 1The Classification of Cardiogenic ShockStageDescriptionBedside FindingsBiomarkersHemodynamicsA – At riskNo current evidence of cardiogenic shock, though remains at riskWarm and well- perfused. Awake and interactiveBaseline renal function. Normal lactateNormotensive for patient baseline. Normal cardiac indexB – BeginningRelative hypotension or tachycardia without malperfusionWarm and well- perfused. Awake and interactive. Signs of volume overload, such as elevated jugular venous pressure and basilar ralesMinimal changes in renal function Normal lactate Elevated natriuretic peptideRelative hypotension from patient baseline, tachycardia, normal cardiac indexC – ClassicClinical malperfusion requiring interventionCold and clammy Mottled and dusky Ventilatory support Altered mental status Decreased urine outputRising creatinine and lactate. Liver injury pattern. Elevated natriuretic peptideRelative hypotension from patient baseline requiring medical and/or mechanical circulatory support. Depressed cardiac indexD – DeterioratingFailure to respond to initial interventions and continuing to worsenFurther worsening from stage CFurther worsening from stage CRequirement for multiple vasopressors and/or addition of mechanical circulatory support devicesE – ExtremisExperiencing cardiac arrest with ongoing medical and mechanical cardiopulmonary resuscitationCardiac collapse Mechanical ventilation DefibrillationFurther worsening from stage DPersistent hypotension despite maximal supportAdapted from reference 10. No copyright required because this table has been modified. Open table in a new tab Adapted from reference 10. No copyright required because this table has been modified. Despite its benefits, not all patients presenting with acute myocardial infarction complicated by cardiogenic shock will require mechanical support before coronary intervention.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar Those patients at risk (class A) or in early shock (class B) can proceed directly for coronary revascularization, with continuous reassessment for progression of shock.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar The cardiovascular anesthesiologist and intensivist will be involved only if these patients manifest later stages of shock (class C-E), to assist in management plans for stabilization and salvage. The management approach to these early tiers of cardiogenic shock focus includes optimization of acid-base balance, blood pressure, and oxygenation, with the goal to preserve and enhance end-organ perfusion before definitive intervention of culprit coronary revascularization.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar Further recommendations include maintaining mean arterial blood pressure >65 mmHg, favoring norepinephrine as first-line vasopressor, and assessing for early indications to consider endotracheal intubation and mechanical ventilation.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar After clinical stabilization, the care team should delineate the cause of shock through detailed physical examination, echocardiography, and catheterization, and consider indications for mechanical circulatory support.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar There is considerable equipoise in evidence supporting pulmonary artery catheterization, with regional variations in clinical practice.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar In the cardiogenic shock population, however, there likely is clinical value for this monitoring modality.12Saxena A Garan AR Kapur NK et al.Value of hemodynamic monitoring in patients with cardiogenic shock undergoing mechanical circulatory support.Circulation. 2020; 141: 1184-1197Crossref PubMed Scopus (46) Google Scholar Saxena et al. provided a robust review, including the multiple data points, with the pulmonary artery catheter in the setting of the different phenotypes of cardiogenic shock.12Saxena A Garan AR Kapur NK et al.Value of hemodynamic monitoring in patients with cardiogenic shock undergoing mechanical circulatory support.Circulation. 2020; 141: 1184-1197Crossref PubMed Scopus (46) Google Scholar These authors have developed a compelling argument in favor of the pulmonary artery catheter in the setting of cardiogenic shock with mechanical circulatory support.12Saxena A Garan AR Kapur NK et al.Value of hemodynamic monitoring in patients with cardiogenic shock undergoing mechanical circulatory support.Circulation. 2020; 141: 1184-1197Crossref PubMed Scopus (46) Google Scholar The phenotypic spectrum of cardiogenic shock includes diastolic heart failure, right-sided heart failure, left-sided heart failure, and biventricular heart failure, with each type requiring different interventions and management.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar,12Saxena A Garan AR Kapur NK et al.Value of hemodynamic monitoring in patients with cardiogenic shock undergoing mechanical circulatory support.Circulation. 2020; 141: 1184-1197Crossref PubMed Scopus (46) Google Scholar After diagnosis, classification, and acute stabilization, those patients with persistent shock evidenced by end-organ malperfusion will benefit from mechanical circulatory support as a way to decrease ventricular work, increase systemic perfusion, and provide hemodynamic support during and after intervention.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar Although the clinical rationale for mechanical circulatory support in acute myocardial infarction with cardiogenic shock is physiologically appealing and supported by observational studies, its role continues to evolve with advances in hardware design and increasing clinical dissemination.12Saxena A Garan AR Kapur NK et al.Value of hemodynamic monitoring in patients with cardiogenic shock undergoing mechanical circulatory support.Circulation. 2020; 141: 1184-1197Crossref PubMed Scopus (46) Google Scholar, 13Basir MB Schreiber TL Grines CL et al.Effect of early initiation of mechanical circulatory support on survival in cardiogenic shock.Am J Cardiol. 2017; 119: 845-851Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar, 14Thiele H Schuler G Neumann FJ et al.Intraaortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock: design and rationale of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial.Am Heart J. 2012; 163: 938-945Crossref PubMed Scopus (108) Google Scholar, 15Cheng JM den Uil CA Hoeks SE et al.Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: A meta-analysis of controlled trials.Eur Heart J. 2009; 30: 2102-2108Crossref PubMed Scopus (394) Google Scholar, 16m Faluk SM Hasan Jiang T et al.Mechanical circulatory assist devices; avilable modalities and review of literature.Heart Views. 2020; 21: 269-275PubMed Google Scholar, 17Shawiarski K Ramakrishna H. Left ventricular mechnaical circulatory support - assessign outcomes with new data.J Cardiothorac Vasc Anesth. 2021; 35: 2499-2502Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Although a comprehensive review of the options for mechanical circulatory support is outside the scope of this editorial, this area has been a steady focus for the Journal and its community due to the growing clinical applicability, the development of protocolized care, and an increasing understanding of complications in mechanical circulatory support both within and beyond the clinical spectrum of acute coronary syndromes.17Shawiarski K Ramakrishna H. Left ventricular mechnaical circulatory support - assessign outcomes with new data.J Cardiothorac Vasc Anesth. 2021; 35: 2499-2502Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 18Cotter EK Banayan J Tung A et al.Trends and outcomes of mechanical circulatory support in peripartum women 2002-2014: A nationwide inpatient sample analysis.J Cardiothoracic Vasc Anesth. 2020; 34: 1198-1203Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 19Gorbea M. A review of physiologic considerations and challenges in pediatric patients with failing single-ventricle physiologyundergoing ventricularassist device placement [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021; (Accessed July 10, 2021)https://doi.org/10.1053/j.jvca.2021.05.045Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 20Welker C Huang J. Ramakrishna H. Analysis of the 2020 EACTS/ELS/ELSO/STS/AATS expert guidelines on the management of adult post-cardiotomy extracorporal life support [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021; (Accessed July 10, 2021)https://doi.org/10.1053/j.jvca.2021.06.022Abstract Full Text Full Text PDF Scopus (1) Google Scholar Further multicenter trials likely will determine the future management approaches in this area.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar,17Shawiarski K Ramakrishna H. Left ventricular mechnaical circulatory support - assessign outcomes with new data.J Cardiothorac Vasc Anesth. 2021; 35: 2499-2502Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 18Cotter EK Banayan J Tung A et al.Trends and outcomes of mechanical circulatory support in peripartum women 2002-2014: A nationwide inpatient sample analysis.J Cardiothoracic Vasc Anesth. 2020; 34: 1198-1203Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 19Gorbea M. A review of physiologic considerations and challenges in pediatric patients with failing single-ventricle physiologyundergoing ventricularassist device placement [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021; (Accessed July 10, 2021)https://doi.org/10.1053/j.jvca.2021.05.045Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 20Welker C Huang J. Ramakrishna H. Analysis of the 2020 EACTS/ELS/ELSO/STS/AATS expert guidelines on the management of adult post-cardiotomy extracorporal life support [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021; (Accessed July 10, 2021)https://doi.org/10.1053/j.jvca.2021.06.022Abstract Full Text Full Text PDF Scopus (1) Google Scholar The decision to employ mechanical circulatory support must be made following careful consideration of the individual patient, underlying shock phenotype, timing of device insertion, and associated device risks.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar The factors that may favor early mechanical circulatory support include refractory cardiopulmonary instability, high-risk coronary anatomy, and severe ventricular dysfunction.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar The factors that may preclude early application of mechanical circulatory support include low level of institutional experience and hostile vascular anatomy.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar After coronary intervention and revascularization in acute myocardial infarction complicated by cardiogenic shock, these patients must be readied for transport to and further management in the intensive care unit.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar A systematic checklist safely can facilitate this transition in complex clinical care, with a review of factors such as hemostasis at access sites, electrical and hemodynamic stability, confirmation of mechanical circulatory support positioning, respiratory stability, and vascular access.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar The role for specialized centers is further evident in the advanced delivery of care during the post-intervention and recovery phase that includes the weaning of mechanical circulatory support. The roles for the cardiovascular anesthesia team in caring for this patient population will only continue to a growing presence in clinical venues, such as the cardiac catheterization laboratory and the specialized heart and vascular intensive care unit. As members of the multidisciplinary care teams in these complex environments, it remains important for us to understand the drugs and devices and also to have a consistent approach to the diagnosis and management of cardiogenic shock, as highlighted in the recent scientific statement from the American Heart Association.1Henry TD Tomey MI Tamis-Holland JE et al.Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association.Circulation. 2021; 143: e815-e829Crossref PubMed Scopus (17) Google Scholar None.