PURPOSE OF REVIEW: This article offers an overview of recent randomized controlled trials (RCTs) testing the efficacy of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and microaxial flow pump (mAFP) in treating cardiogenic shock, including findings from the DanGer shock trial. It summarizes the clinical implications and limitations of these studies and key decision-making considerations for cardiogenic shock device use. RECENT FINDINGS: Despite important limitations in all published RCTs, the routine use of VA ECMO for acute myocardial infarction related cardiogenic shock did not demonstrate benefit and should be reserved for selected patients with extreme forms of cardiogenic shock. Conversely, mAFP (Impella CP) appears promising for cardiogenic shock due to ST elevation myocardial infarction. A stepwise approach - initial mAFP use for cardiogenic shock with left ventricular failure, supplemented by VA ECMO if mAFP is inadequate or if severe right ventricular failure is present - may be preferable, but requires validation through RCTs. High complication rates in device arms underscore the need for careful patient selection, preventive strategies, education for centers and operators, and further research. SUMMARY: Recent trials offer insights into mechanical circulatory support in cardiogenic shock, but their real-world applicability is limited. Despite potential benefits, the use of VA ECMO and mAFP is associated with significant complication rates, emphasizing the need for personalized use.

Department of Medicine Department of Cardiovascular Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Prague Czech Republic

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van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation 2017; 136:232–268.

Helgestad OKL, Josiassen J, Hassager C, et al. Temporal trends in incidence and patient characteristics in cardiogenic shock following acute myocardial infarction from 2010 to 2017: a Danish cohort study. Eur J Heart Fail 2019; 21:1370–1378.

Ostadal P, Rokyta R, Karasek J, et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation 2023; 147:454–464.

Thiele H, Zeymer U, Akin I, et al. Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med 2023; 389:1286–1297.

Zeymer U, Freund A, Hochadel M, et al. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials. Lancet 2023; 402:1338–1346.

Møller JE, Engstrøm T, Jensen LO, et al. Microaxial flow pump or standard care in infarct-related cardiogenic shock. N Engl J Med 2024; 390:1382–1393.

Møller JE, Sionís A, Aïssaoui N, et al. Step by step daily management of short-term mechanical circulatory support for cardiogenic shock in adults in the intensive cardiac care unit: a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology SC, the European Society of Intensive Care Medicine, the European branch of the Extracorporeal Life Support Organization, and the European Association for Cardio-Thoracic Surgery. Eur Heart J Acute Cardiovasc Care 2023; 12:475–485.

Naidu SS, Baran DA, Jentzer JC, et al. SCAI SHOCK stage classification expert consensus update: a review and incorporation of validation studies. J Am Coll Cardiol 2022; 79:933–946.9.

Anderson RJ, Jinadasa SP, Hsu L, et al. Shock subtypes by left ventricular ejection fraction following out-of-hospital cardiac arrest. Crit Care 2018; 22:4–5.

Belohlavek J, Smalcova J, Rob D, et al. Effect of intra-arrest transport, extracorporeal cardiopulmonary resuscitation, and immediate invasive assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest. JAMA 2022; 327:737.

Brunner S, Guenther SPW, Lackermair K, et al. Extracorporeal life support in cardiogenic shock complicating acute myocardial infarction. J Am Coll Cardiol 2019; 73:2355–2357.

Banning AS, Sabaté M, Orban M, et al. Venoarterial extracorporeal membrane oxygenation or standard care in patients with cardiogenic shock complicating acute myocardial infarction: the multicentre, randomised EURO SHOCK trial. EuroIntervention 2023; 19:482–492.

Bochaton T, Huot L, Elbaz M, et al. Mechanical circulatory support with the Impella® LP5.0 pump and an intra-aortic balloon pump for cardiogenic shock in acute myocardial infarction: the IMPELLA-STIC randomized study. Arch Cardiovasc Dis 2020; 113:237–243.

Ouweneel DM, Eriksen E, Sjauw KD, et al. Percutaneous mechanical circulatory support versus intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol 2017; 69:278–287.

Seyfarth M, Sibbing D, Bauer I, et al. A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction. J Am Coll Cardiol 2008; 52:1584–1588.

Rob D, Kavalkova P, Smalcova J, et al. Coronary angiography and percutaneous coronary intervention in cardiac arrest patients without return of spontaneous circulation. Resuscitation 2022; 175:133–141.

Brusca SB, Caughron H, Njoroge JN, et al. The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock. Curr Opin Cardiol 2022; 37:241–249.

Na SJ, Chung CR, Choi HJ, et al. The effect of multidisciplinary extracorporeal membrane oxygenation team on clinical outcomes in patients with severe acute respiratory failure. Ann Intensive Care 2018; 8:

Lorusso R, Shekar K, MacLaren G, et al. ELSO Interim Guidelines for venoarterial extracorporeal membrane oxygenation in adult cardiac patients. ASAIO J 2021; 67:827–844.

Schrage B, Becher PM, Bernhardt A, et al. Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation. Circulation 2020; 142:2095–2106.

Schrage B, Sundermeyer J, Blankenberg S, et al. Timing of active left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation therapy. JACC Heart Fail 2023; 11:321–330.