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New percutaneous mechanical left ventricular support for acute MI: the AMC MACH program

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 62–63 (2008)Cite this article

Cardiogenic shock is estimated to occur in approximately 7–10% of patients with acute ST-segment elevation myocardial infarction (STEMI).1 Despite clinical advances in the treatment of STEMI, cardiogenic shock remains the leading cause of death in patients hospitalized with this condition.1 The SHOCK trial2 demonstrated that, even with prompt treatment, in-hospital mortality was 35% in STEMI patients treated with revascularization. We must find ways to address this unacceptably high mortality, rather than simply accept that these patients have a high risk of death. In this Viewpoint we discuss how newly available percutaneous left ventricular (LV) assist devices (LVADs) could help resolve this issue.

Coronary reperfusion can now be achieved with primary percutaneous coronary intervention (PCI) in more than 90% of patients with STEMI. Although this treatment limits infarct size, the viable myocardium needs time to recuperate from ischemic stunning before taking part in LV contraction. According to current guidelines, patients with STEMI who present in a preshock state should be treated as though they were in cardiogenic shock.3,4 Intra-aortic balloon counterpulsation (IABP) therapy might be required if the patient is hypotensive.3,4 This treatment reduces afterload, increases coronary perfusion and augmented diastolic blood pressure, and improves cardiac output. There is no evidence, however, that IABP therapy improves patient outcome. A total of seven randomized trials of IABP therapy have been conducted (two in the prereperfusion era, two using thrombolysis for reperfusion, and three using PCI), and none has shown an improvement in clinical outcome with this treatment. A recent meta-analysis of these seven trials (>1,000 patients) also demonstrated that IABP therapy did not result in improved clinical outcome (KD Sjauw et al., unpublished data). In fact, the randomized studies in STEMI patients treated with primary PCI showed that IABP therapy was associated with an increase in the number of adverse events. Furthermore, the largest observational study to date of STEMI patients presenting with cardiogenic shock treated with PCI (>2,900 patients) did not show a clinical benefit with IABP, and this therapy was actually an independent predictor for mortality in multivariate analysis.5 Cardiologists continue to use IABP therapy, however, and this treatment is listed, in the US and Europe, as a class IB recommendation for STEMI when cardiogenic shock is not quickly reversed.

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Authors and Affiliations

  1. JPS Henriques is staff cardiologist and Leader of the AMC MACH program and BAJM de Mol is Professor and Chief of Cardiothoracic Surgery at the Academic Medical Center, Amsterdam, The Netherlands.,

    José PS Henriques

  2. Professor de Mol is also a part-time Professor of Biomedical Engineering at the Technical University Eindhoven, The Netherlands.,

    Bas AJM de Mol

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  1. José PS Henriques
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Correspondence to José PS Henriques.

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Competing interests

JPS Henriques has received an unrestricted educational grant from Abiomed. BAJM de Mol declared no competing interests.

Supplementary information

Supplementary Figure 1

The AMC MACH program: LVAD in the catheterization laboratory and beyond (PPT 545 kb)

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Henriques, J., de Mol, B. New percutaneous mechanical left ventricular support for acute MI: the AMC MACH program. Nat Rev Cardiol 5, 62–63 (2008). https://doi.org/10.1038/ncpcardio1060

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