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MCS Device Hierarchy — EECC MCQ

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HardCoronary Artery DiseaseMCS Device HierarchyEECC

A 58-year-old man presents with STEMI and cardiogenic shock. Despite successful primary PCI to the culprit LAD, he remains hypotensive (SBP 70 mmHg) with a cardiac index of 1.6 L/min/m² on inotropes. What mechanical circulatory support (MCS) device provides the greatest haemodynamic support?

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Correct answer: A — VA-ECMO (veno-arterial extracorporeal membrane oxygenation) — provides the highest level of circulatory support (up to 6-7 L/min flow) with oxygenation capability, serving as a bridge to recovery, decision, or further therapy

MCS devices in cardiogenic shock provide escalating levels of support: (1) IABP: modest support (~0.5 L/min augmentation), counterpulsation reduces afterload and improves coronary perfusion — the IABP-SHOCK II trial showed no mortality benefit in STEMI cardiogenic shock, downgrading IABP from Class I to IIb; (2) Impella CP/5.0/5.5: 3-5 L/min axial flow pump placed across the aortic valve; (3) VA-ECMO: 4-7 L/min, provides both circulatory support AND gas exchange — highest level of support, used as a bridge to recovery, LVAD, or transplant. The ESC 2023 ACS Guidelines recommend considering MCS in refractory cardiogenic shock (Class IIb), though the ECLS-SHOCK trial showed VA-ECMO did not reduce 30-day mortality versus standard care in STEMI cardiogenic shock.

Reference: ESC (2023): ACS Guidelines; IABP-SHOCK II/ECLS-SHOCK Trials