Optimizing the patient and timing of the introduction of mechanical circulatory and extracorporeal respiratory support

Abstract

Evolution of extracorporeal and implantable cardiorespiratory mechanical assist devices has added a new dimension to the management of patients with acute refractory cardiac and/or respiratory failure or in those who have end-stage cardiorespiratory disease. These devices serve as a viable bridge to decision or recovery, destination device, or transplantation. While the current generation of devices has evolved significantly, maximizing the likelihood of a successful outcome depends on thorough understanding of patient pathophysiology, early recognition of failure of conventional therapies, careful patient selection, and timely initiation of mechanical support. The risk-benefit ratios of various available mechanical assist devices, surgical techniques, and possible perfusion strategies applied are equally important. Currently, there are no clear data to indicate when the benefits of initiating temporary mechanical circulatory and extracorporeal respiratory support outweigh the risks of continuing with conventional therapies. However, there are some data to guide the timing of long-term MCS devices, which indicate that these devices should be implanted where possible in patients who are relatively stable on inotropic support. This review provides a summary of available literature in this regard. Further clinical research is necessary to specifically address the efficacy of various optimization strategies discussed in this review.