Can we have a rationalized selection of intra-aortic balloon pump, Impella, and extracorporeal membrane oxygenation in the catheterization laboratory?

Cardiac assistance represents an emerging issue in cardiovascular medicine. The evolution of invasive cardiology techniques is making the catheterization laboratory one of the main hospital sites where implantation of percutaneous ventricular assistance devices (PVADs) is discussed and performed. Among available PVADs, intra-aortic balloon pump (IABP), Impella, and extracorporeal membrane oxygenation (ECMO) are the most popular and offer completely different levels and ways to assist critical patients. The main settings calling for PVAD consideration in the catheterization laboratory are clinically indicated high-risk patients (CHIP) undergoing percutaneous coronary intervention (PCI) and patients with cardiogenic shock or refractory cardiac arrest. In CHIP, PVAD serves the purpose of preventing hemodynamic collapse during PCI. This may also allow more extensive revascularizations and higher quality revascularization plans (imaging use, debulking, stent result optimization). IABP or Impella are more commonly selected whereas ECMO is seldom considered as a third option for highly selected patients. The "elective" nature of CHIP-PCI should allow careful procedure planning (peripheral artery disease assessment, access site selection and management) in order to minimize vascular/bleeding complications. Cardiogenic shock is still associated with high mortality rates, and PVAD theoretically offers further recovery chances. The lack of benefit observed with systematic IABP use is currently prompting consideration of the roles of Impella and ECMO. Prolonged assistance is often needed. Thus, team decisions and shared protocols for PVAD selection have to be promoted, taking into consideration available resources and operators' skills. In this paper, we critically review the available data in the field and highlight the possible decisionmaking hubs that catheterization-laboratory teams may consider in order to rationalize PVAD selection.