From Rescue to Replacement: Integrating Temporary and Durable Mechanical Circulatory Support Across the Cardiogenic Shock–Heart Failure Continuum: A narrative review

Abstract

Heart failure (HF) and cardiogenic shock (CS) represent a continuum of cardiac dysfunction with substantial morbidity and mortality. Timely and appropriate mechanical circulatory support (MCS) can be lifesaving. Although the use of temporary and durable devices continues to expand, evidence guiding their optimal integration across the HF–CS spectrum remains limited. This review examines the integration of temporary and durable MCS to improve patient outcomes.

A comprehensive literature review (2020–2025) of 94 articles, including RCTs, registry analyses, and international guidelines from Cochrane, PubMed, JACC, ClinicalTrials.gov, was performed. Included were adults (≥18 years) with advanced HF or CS using MCS. Exclusions comprised pediatric data, case reports, editorials, correspondence, and non-MCS-specific or non-English studies.

Systematic synthesis of the included literature demonstrated that the integration of protocolized temporary MCS (Intra-Aortic Balloon Pump, Impella, Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO)) programs, such as the Inova Heart and Vascular Institute (IHVI) program, was associated with improved 30-day survival (57% to 71%). Prognostic indicators for poor mortality included low Cardiac Power Output and elevated lactate. And for program survivors most common destination was left ventricular assist device (LVAD 14%) or heart transplantation (3%) at 36-month follow-up. While registry data (e.g., Extracorporeal Life Support Organization (ELSO), n=7,950) attained early physiologic objectives that boosted VA-ECMO survival (39% to 56%) and reduced complications, temporary support still demonstrated high complication rates, with Impella evaluations showing mortality near 30% and frequent hemorrhage/vascular injury. Conversely, the Aspirin Removal and Investigation of Events Surrounding the HeartMate3 (ARIES-HM3 LVAD) research demonstrated that optimizing anticoagulation by removing aspirin significantly reduced bleeding without increasing thrombosis.

HF–CS continuum research suggests combining temporary devices and durable MCS increases survival. While enhanced anticoagulation reduces bleeding, timely physiologic adjustment and systematic protocol implementation enhance outcomes. Randomized trials are necessary to identify the optimal sequencing and transition strategies due to outcome unpredictability.