Rapid Application Is Crucial
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In the section on mechanical circulatory support , the authors mention the option of using ventricular assist devices (VADs) or extracorporeal membrane oxygenation (ECMO/ECLS) only if the cause of the cardiogenic shock is potentially reversible (1).
The presence of a reversible cause is not crucial for the treatment with mechanical circulatory support (MCS) systems. On the contrary, we wish to suggest making the decision in favor of implantation on the basis of a patient’s prognosis once heart failure has been removed from the scenario. If cardiac function improves under MCS then the system can be explanted without any substitute. If the patient’s general condition stabilizes but his/her heart function remains unsatisfactory (in a scenario of an otherwise acceptable prognosis!) a change to a permanent VAD (or even heart transplantation) is possible.
What is crucial is that mechanical support is administered as rapidly as possible, as the success rate of such systems decreases in tandem with the increasing extent of the shock (2).
Acutely decompensated chronic heart failure is a primary focus of the article. In this context the role of MCS should be explicitly mentioned. According to the ESC guidelines, VAD implantation is indicated if a patient who receives adequate medication recurrently decompensates and, in addition to left ventricular heart failure, is found to have impaired right ventricular function and secondary organ function impairments (reduced liver or kidney function) (3). We see this constellation often in our clinical practice, with patients not being informed about the option of VAD implantation. If the device is implanted only in the context of hemodynamic decompression, the chance of success is clearly lower (4).
Dr. med. Felix Hennig
PD Dr. med. Evgenij V. Potapov
Prof. Dr. med. Volkmar Falk
Prof. Dr. med. Thomas Krabatsch
on behalf of the MCS-Team Deutsches Herzzentrum Berlin
Conflict of interest statement
Dr Potapov has been reimbursed conference delegate fees by HeartWare and travel and hotel expenses from HeartWare and Thoratec. He has received study support from Berlin Heart, HeartWare, and Thoratec for a research project that he himself initiated.
Prof. Falk has received consultancy fees from Berlin Heart and HeartWare. He has been reimbursed conference delegate fees and travel and hotel expenses from Berlin Heart, HeartWare, Edwards, Medtronic, and St Jude Medical. He has received study support from Philips and Siemens for a research project that he himself initiated. He has received funding from Berlin Heart and HeartWare for carrying out clinical studies.
Dr Hennig and Prof. Krabatsch declare that no conflict of interest exists.
|1.||Hummel A, Empen K, Dörr M, Felix SB: De novo acute heart failure and acutely decompensated chronic heart failure. Dtsch Arztebl Int 2015; 112: 298–310 VOLLTEXT|
|2.||Lebreton G, Pozzi M, Mastroianni C, Léger P, Pavie A, Leprince P: Extracorporeal life support as a bridge to bridge: a strategy to optimize ventricular assist device results. Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezu516 CrossRef|
|3.||McMurray JJ, Adamopoulos S, Anker SD, et al.: ESC guidelines for the diagnosis and treatment of acute and chronic heart fail- ure 2012: The task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33: 1787–847 CrossRef MEDLINE|
|4.||Kirklin JK, Naftel DC, Pagani FD, et al.: Sixth INTERMACS annual report: A 10 000-patient database. J Heart Lung Transplant 2014; 33: 555–64 CrossRef MEDLINE|