University Hospitals Sussex NHS Foundation Trust, Brighton and Hove, Sussex, UK.
Aston Medical School, Aston University, Birmingham, UK.
Exp Physiol. 2024 Nov;109(11):1826-1836. doi: 10.1113/EP091796. Epub 2024 Oct 14.
Heart failure represents a dynamic clinical challenge with the continuous rise of a multi-morbid and ageing population. Yet, the evolving nature of mechanical circulatory support offers a variety of means to manage candidates who might benefit from such interventions. This narrative review focuses on the role of the main mechanical circulatory support devices, such as ventricular assist device, extracorporeal membrane oxygenation, Impella and TandemHeart, in the physiological process of ventricular unloading and remodelling in heart failure, highlighting their characteristics, mechanism and clinical outcomes. The outcome measures described include physiological changes (i.e., stroke volume or preload and afterload), intracardiac pressure (i.e., end-diastolic pressure) and extracardiac pressure (i.e., pulmonary capillary wedge pressure). Overall, all the above mechanical circulatory support strategies can facilitate the unloading of the ventricular failure through different mechanisms, which subsequently affects the ventricular remodelling process. These physiological changes start immediately after ventricular assist device implantation. The devices are indicated in different but overlapping populations and operate in distinctive ways; yet, they have evidenced performance to a favourable standard to improve cardiac function in heart failure, although this proved variable for different devices, and further high-quality trials are vital to assess their clinical outcomes further. Both Impella and TandemHeart are indicated mainly in cardiogenic shock and high-risk percutaneous coronary intervention patients; at the time the literature was evaluated, both devices were found to yield a significant improvement in haemodynamics but not in survival. Nevertheless, the choice of device strategy should be based on individual patient factors, including indication, to optimize clinical outcomes.
心力衰竭是一个具有挑战性的临床难题，随着多病共存和人口老龄化的不断增加，其发病率持续上升。然而，机械循环支持的不断发展为管理可能受益于此类干预的患者提供了多种手段。本综述重点介绍了心室辅助装置、体外膜肺氧合、Impella 和 TandemHeart 等主要机械循环支持设备在心衰心室卸载和重塑的生理过程中的作用，强调了它们的特点、作用机制和临床结局。描述的结局指标包括生理变化（即每搏量或前负荷和后负荷）、心内压（即舒张末期压）和心外压（即肺毛细血管楔压）。总的来说，所有上述机械循环支持策略都可以通过不同的机制促进心室衰竭的卸载，进而影响心室重塑过程。这些生理变化在心室辅助装置植入后立即发生。这些设备适用于不同但重叠的人群，并以不同的方式运作；然而，它们已经证明了在改善心力衰竭心脏功能方面的性能达到了有利的标准，尽管不同设备的效果不同，进一步的高质量试验对于评估它们的临床结局至关重要。Impella 和 TandemHeart 主要适用于心源性休克和高危经皮冠状动脉介入治疗患者；在评估文献时，发现这两种设备都能显著改善血液动力学，但不能提高生存率。然而，设备策略的选择应基于患者的个体因素，包括适应证，以优化临床结局。
