Mechanical circulatory support and the need for hemodynamic coherence

Cardiogenic shock (CS) is a common disorder in critically ill patients. Several underlying etiologies such as myocarditis, acute myocardial infarction (AMI), peripartum cardiomyopathy, decompensated chronic heart failure, and postcardiotomy shock are responsible for and result in abnormalities in the microcirculation (MC) and tissue hypoxia . In this review, we investigated the current state of knowledge concerning the response of MC to CS in patients on mechanical circulatory support (MCS) devices and descriptions of the presence of hemodynamic coherence between macrocirculation and MC.

MCS using different techniques has become a realistic and cost-effective option to reverse shock and prevent secondary organ failure while waiting for a permanent solution. With the advent of different types of devices, circulatory collapse can be treated effectively; however, end-organ recovery is not always achieved. When recovery is not anticipated, a plan for urgent heart transplantation (HT), or for a durable MCS (such as left ventricular assist device (LVAD) implantation as a “bridge to bridge” or “bridge to destination”), or for withdrawal of support (“bridge to palliative care”) needs to be made. Current knowledge is, however, limited and controversy exists regarding the response of the MC of patients treated with mechanical support devices .

Understanding the functional condition of the MC may improve clinical outcomes of the critically ill patients . Direct monitoring of the MC by handheld microscopy may provide a more physiological approach than solely monitoring the systemic circulation for clinicians to evaluate the efficacy of therapy and help to assess the presence of hemodynamic coherence between the macrocirculation and MC . In this paper, we review studies that have documented measurement of hemodynamic variables related to the systemic circulation and the MC in response to MCS of the heart.

Methods

By using Cochrane Central Register of Controlled Trials, Embase, and Medline (PubMed US National Library of Medicine), we performed a literature search in June 2016 using the following search terms: (1) “heart-assist devices” (MeSH Terms) AND (“heart failure” (MeSH Terms) OR “shock, cardiogenic” (MeSH Terms)) AND “microcirculation” (text word); and (2) extracorporeal membrane oxygenation (MeSH Terms) OR mechanical circulatory support (text word) OR intraaortic counter-pulsation (text word). From embase.com , we found 1080 items; here, we give an example: “microcirculation”/de OR “microvascular ischemia”/de OR microvasculature/exp OR “microvascularization”/de OR “capillary density”/de OR (microcirculat* OR microvascu* OR microvessel* OR ((vessel* OR capillar*) NEAR/3 (densit* OR perfuse* OR imag* OR microscop*) OR if OR (incident* NEAR/3 (darkfield OR dark-field OR sidestream OR side-stream)) OR ops OR (orthogonal* NEAR/3 polari* NEAR/3 spectr*) OR SDF OR ((darkfield OR dark-field) NEAR/3 (sidestream OR side-stream)):ab,ti) AND (“extracorporeal oxygenation”/de OR “extracorporeal circulation”/de OR “cardiopulmonary bypass”/de OR “implanted counterpulsation device”/exp OR “aorta balloon”/de OR “left ventricular assist device”/de OR “heart lung machine”/de OR “heart assist device”/exp OR “assisted circulation”/de OR (extracorpor* NEAR/3 (oxygenat* OR mechanic* OR circulat*)) OR (cardiopulmon* NEAR/3 bypass*) OR ecmo OR ((intraaort* OR intra-aort*) NEAR/3 balloon NEAR/3 pump*) OR (implant* NEAR/3 (counterpulsat* OR counter-pulsat*)) OR ((ventric* OR heart OR cardiac) NEAR/3 assist* NEAR/3 device*) OR CorAide OR DeBakey-Child OR DuraHeart OR EVAHEART OR EXCOR OR FlowMaker OR HeartMate OR HeartQuest OR Impella OR LP2-5 OR LP5 OR INCOR OR Left-VAD OR IABP OR Levacor OR Lion-Heart OR LionHeart OR LV-assist-device* OR LVAD OR MiTi-Heart OR Novacor OR TandemHeart OR Ventrassist OR Centrimag OR Levitronix OR ((mechanical* OR device*) NEAR/3 support* NEAR/3 (heart OR cardiac)) OR ((heart OR cardiac) NEAR/3 (lung OR pulmonar*) NEAR/3 machine*) OR ((assist* OR mechanical* OR artificial*) NEAR/3 (circulation* OR heart OR cardiac)) OR blood-pump*):ab,ti) NOT ([animals]/lim NOT [humans]/lim) .

Two investigators (S.A. and A.K.) independently retrieved potentially eligible reports for evaluation. Both investigators independently examined design, patient population, and interventions in the reports. In case of disagreement, this was resolved in consultation with two other reviewers (C.A.U. and C.I.).

Methods

By using Cochrane Central Register of Controlled Trials, Embase, and Medline (PubMed US National Library of Medicine), we performed a literature search in June 2016 using the following search terms: (1) “heart-assist devices” (MeSH Terms) AND (“heart failure” (MeSH Terms) OR “shock, cardiogenic” (MeSH Terms)) AND “microcirculation” (text word); and (2) extracorporeal membrane oxygenation (MeSH Terms) OR mechanical circulatory support (text word) OR intraaortic counter-pulsation (text word). From embase.com , we found 1080 items; here, we give an example: “microcirculation”/de OR “microvascular ischemia”/de OR microvasculature/exp OR “microvascularization”/de OR “capillary density”/de OR (microcirculat* OR microvascu* OR microvessel* OR ((vessel* OR capillar*) NEAR/3 (densit* OR perfuse* OR imag* OR microscop*) OR if OR (incident* NEAR/3 (darkfield OR dark-field OR sidestream OR side-stream)) OR ops OR (orthogonal* NEAR/3 polari* NEAR/3 spectr*) OR SDF OR ((darkfield OR dark-field) NEAR/3 (sidestream OR side-stream)):ab,ti) AND (“extracorporeal oxygenation”/de OR “extracorporeal circulation”/de OR “cardiopulmonary bypass”/de OR “implanted counterpulsation device”/exp OR “aorta balloon”/de OR “left ventricular assist device”/de OR “heart lung machine”/de OR “heart assist device”/exp OR “assisted circulation”/de OR (extracorpor* NEAR/3 (oxygenat* OR mechanic* OR circulat*)) OR (cardiopulmon* NEAR/3 bypass*) OR ecmo OR ((intraaort* OR intra-aort*) NEAR/3 balloon NEAR/3 pump*) OR (implant* NEAR/3 (counterpulsat* OR counter-pulsat*)) OR ((ventric* OR heart OR cardiac) NEAR/3 assist* NEAR/3 device*) OR CorAide OR DeBakey-Child OR DuraHeart OR EVAHEART OR EXCOR OR FlowMaker OR HeartMate OR HeartQuest OR Impella OR LP2-5 OR LP5 OR INCOR OR Left-VAD OR IABP OR Levacor OR Lion-Heart OR LionHeart OR LV-assist-device* OR LVAD OR MiTi-Heart OR Novacor OR TandemHeart OR Ventrassist OR Centrimag OR Levitronix OR ((mechanical* OR device*) NEAR/3 support* NEAR/3 (heart OR cardiac)) OR ((heart OR cardiac) NEAR/3 (lung OR pulmonar*) NEAR/3 machine*) OR ((assist* OR mechanical* OR artificial*) NEAR/3 (circulation* OR heart OR cardiac)) OR blood-pump*):ab,ti) NOT ([animals]/lim NOT [humans]/lim) .

Two investigators (S.A. and A.K.) independently retrieved potentially eligible reports for evaluation. Both investigators independently examined design, patient population, and interventions in the reports. In case of disagreement, this was resolved in consultation with two other reviewers (C.A.U. and C.I.).

Study selection

All retrospective and prospective cohort studies with MC on adult patients receiving short-term (hours to weeks) and long-term (weeks to years) MCS for CS and acute/chronic heart failure were selected ( Fig. 1 ). We excluded reports on review articles, abstracts, animal studies, duplicates, pediatrics, case reports, and perioperative studies on heart–lung machines. Further selection was made including only reports of microcirculatory measurements in short- and long-term MCS. Finally, after excluding reports where both MC and macrocirculation parameters were not evaluated during MCS, 14 studies were left and included in this study.

Identification of studies comparing microcirculation and macrocirculation parameters in short- and long-term MCS.

Study outcomes

All studies related to mechanically supported adult hearts monitored by the measurement of the MC and macrocirculation were evaluated ( Table 1 ).

Results of the literature search

Fourteen studies (N = 157 patients with varying ages (24–80 years)) met the inclusion criteria for this study ( Fig. 1 ). The types of MCS used (n = 112) included intraaortic balloon pump (IABP) (n = 71), biventricular assist device (BiVAD, n = 15), peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO, n = 4), Impella 2.5 (n = 3), TandemHeart (n = 1), and combination of VA-ECMO with IABP (n = 18), and long-term MCS (LVADs (n = 45), HeartMate II (HM II, n = 13), HeartWare (HW, n = 14), MicroMed DeBakey VAD (n = 3), and HeartMate I (HM I, n = 15)) with support duration varying from 1 to 120 days.

Techniques used for microcirculatory assessments included mainly handheld video microscopy using sublingual sidestream dark-field (SDF) imaging (n = 8), laser Doppler perfusion imaging (LDPI, n = 4), tissue electron microscopy (n = 1), and beat-to-beat finger photoplethysmogram (PPG, n = 1) ( Tables 2 and 3 ).

Table 2

Literature overview of microcirculatory and macrocirculatory measurements in short-term MCS.

First author of studies: year	N	Age (years) Mean ± SD or Median (range)	Etiology	Hemodynamic coherence	Used MCS device	Used MC technique	Location of measurement	Microcirculation parameter	Macrocirculation
Bittner:1992	15	24–55	ESHF	Negative	BVAD	LDF	Forearm cutaneous	LDF, PORH	CO, SVR, RR
Den Uil: 2009	13	59 (56–73)	CS	Negative	IABP	SDF	Sublingual mc	PCD, cRBCv	MAP, CI, CPI
Jung: 2009	6	72.2 ± 5.5	HR-PCI	Positive	IABP	SDF	Sublingual mc	MFI; microflow in three vessel categories	RR
Jung: 2009	13	71.1 ± 8.4	CS	Positive	IABP	SDF	Sublingual mc	MFI	CPI, RR, MAP, CO, CI, SVR, CVP, and lactate
Lam: 2009	3	53.6 ± 17.8	STEMI-PCI	Positive	Impella 2.5	SDF	Sublingual mc	MFI, PVD, FCD	LVEF, diastolic RR
Munsterman: 2010	15	65.7 ± 11.8	CS	Negative	IABP	SDF	Sublingual mc	MFI, PVD were significant	RR, MAP, SvO2, HR, CVD, PAP
Petroni: 2014	12	57.3 ± 14.4	CS	Negative	VA-ECMO + IABP	SDF	Sublingual mc	StO2, FCD, MFI, PPV, and heterogeneity, MFI index	PAOP, LVEDD, LVESD, PP
Wester: 2014	8	59 (27–78)	CS	Negative	8 ECMO + 6 IABP	skin vital microscopy and LDPI	Dorsum of the hand, medial side of foot	FCD, HI, CoV	CVD, MAP, HR, SvO2
Jung: 2015	24	69 (56–80)	CS-AMI	Positive	IABP	SDF	Sublingual mc	PCD, PVD, TCD, TVD, and PPV	Lactate, RR, HR

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