EACTS/STS/AATS Guidelines: Temporary Mechanical Circulatory Support (tMCS) In Cardiac Surgery
Landmark Update for Cardiac Surgeons
For the first time, EACTS, STS, and AATS jointly recommend early initiation of temporary mechanical circulatory support (tMCS) as a Class I intervention for patients with cardiogenic shock.
Emphasizing timely support to prevent multi-organ failure, reduce mortality, and optimize outcomes in high-risk surgical patients.
Guideline-Based Recommendations by Indication
The latest guidelines reflect a shift away from high-dose vasoactive drugs (classified as a VIS score >20 with conditions) in favor of temporary MCS in cardiogenic shock thanks to superior support and outcomes—strengthening the recommendation for tMCS use to class 1.
Quantifying Pharmacologic Burden to Guide Timely tMCS
What is the VIS Score?
Objective, quantifiable measurement of vasoactive medication burden.
- Standardizes dosing of different hemodynamic agents to assess shock severity.
- Accurate predictive value for 30-day mortality.
- A guide for clinical recommendations for active unloading, escalation, and weaning of MCS.
Protected Cardiac Surgery
In the setting of cardiogenic shock, guidelines recommend: In patients with LCOS following cardiac surgery, full support mAFP should be prioritized over partial support when feasible.
Key Recommendations:
Class I:
- tMCS for post-procedural LCOS.
- Immediate transition to tMCS if unable to wean from CPB.
- Interdisciplinary Shock Team discussion.
- Early tMCS if difficulty weaning from CPB.
Class IIa:
- Intraoperative tMCS for high-risk LCOS.
AMICS
The randomized DanGer Shock trial found improved survival in patients with ST segment elevation myocardial infarction-CS treated with maFP.
Key Recommendations:
Class I: Initiate tMCS before severe organ dysfunction.
Class IIa: Escalating vasoactive/inotropic drugs or rising lactate → consider tMCS.
Class IIb: tMCS may be considered prior to revascularization.
Advanced Heart Failure
mAFP used as a BTT has demonstrated a 94.8% 1-year survival rate. After risk adjustment, the dLVAD was associated with a 4-fold increase in 1-year deaths compared to mAFP.
Key Recommendations:
Class I: tMCS for deteriorating patients awaiting dMCS/HTx.
Class IIa: Optimize end-organ function before dMCS/HTx.
Biventricular Support
Impella RP Flex™ was designed for ease of delivery via IJ or femoral vein and can be paired with left sided support for Biventricular support.
Key Recommendations:
Class I: Support both ventricles with VA-ECLS + mAFP or dual mAFP/tVAD.
LV Unloading with VA-ECLS
Microaxial flow pumps like Impella™ are a recommended option by EACTS, STS, and AATS for use both alone and in combination with VA-ECLS for advanced left ventricular unloading and biventricular support without the need for an oxygenator in patients with cardiogenic shock.
Key Recommendations:
Class IIa: Initiate LV unloading within 2 hours of VA-ECLS for improved outcomes.
NPS-5410