A historic first in cardiogenic shock: Three societies. One unified voice. 200+ pages of evidence.
Landmark update for cardiac surgery
For the first time, the world’s three leading cardiac surgery societies— the European Association for Cardio-Thoracic Surgery (EACTS), Society of Thoracic Surgeons (STS), and American Association for Thoracic Surgery (AATS) — have jointly published guidelines on the role and timing of temporary mechanical circulatory support (tMCS), like Impella, recommending early initiation of tMCS as a class I intervention for patients with cardiogenic shock.
In the over 200 pages of research and evidence, it’s clear that the guidelines emphasize timely support to prevent multi-organ failure, reduce mortality, and optimize outcomes in high-risk surgical patients.
Quantifying pharmacologic burden to guide timely tMCS
The latest guidelines reflect a shift away from high-dose vasoactive drugs in favor of tMCS in cardiogenic shock. When medication burden becomes high (such as VIS >20), tMCS offers more reliable hemodynamic support and improved outcomes—strengthening its designation as a class I recommendation.
What is VIS and why does it matter?
Vasoactive-Inotropic Score (VIS) is an objective, quantifiable measurement of vasoactive medication burden, helping clinicians understand how much medication support a patient needs and how severe their shock may be. It includes:
- Standardization 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.
Are you a U.S. cardiac surgeon interested in learning more?
Explore upcoming Surgical in-person educational events.
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.
The evidence behind the recommendations
These guideline updates are based on:
- Randomized clinical trials, including DanGer Shock
- Real-world outcomes data
- Expert consensus across multiple international societies
Together, they reflect growing agreement that earlier mechanical circulatory support improves survival and recovery in cardiogenic shock.
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.
Are you a U.S. cardiac surgeon interested in learning more?
Explore upcoming Surgical in-person educational events.
References
- Potapov, E. V., et al. (2025). EACTS/STS/AATS Guidelines on temporary mechanical circulatory support in adult cardiac surgery. European Journal of Cardio-Thoracic Surgery. https://doi.org/10.1093/ejcts/ezaf330
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