Mechanical Circulatory Support/ECMO Indications — free guideline decision tool

This tool guides selection of mechanical circulatory support (IABP, Impella, VA-ECMO, or RV assist) in cardiogenic shock by the type of failure, integrating recent randomized trials and 2023 ESC / 2025 ACC/AHA recommendations.

Decision logic by failure type: isolated LV → Impella (STEMI severe/refractory, IIa); refractory/arrest/cardiopulmonary failure → VA-ECMO ± LV unloading (against routine use; IIb for refractory); RV/biventricular → RV assist or VA-ECMO; mechanical complication → IABP bridge.

Use at the bedside in cardiogenic shock to match the device to the failure pattern — isolated LV, refractory/arrest, RV/biventricular, or mechanical complication — while emphasizing early recognition, referral to experienced centers, and a planned weaning/escalation strategy.

No temporary MCS device holds a Class I recommendation; benefit is limited to selected subgroups, so device choice should be individualized by failure type and center experience. (original synthesis · not guideline verbatim) DanGer Shock (2024) supported Impella in STEMI-CS (upgraded to IIa) at a cost of more bleeding, hemolysis, AKI, and limb ischemia. ECLS-SHOCK (2023) found routine early VA-ECMO did not reduce AMI-CS mortality and increased complications; VA-ECMO often needs LV unloading.

For licensed clinicians and clinical researchers. Interpret results with history, investigations and local protocols; not a diagnosis or prescription, and not a substitute for multidisciplinary decision-making or local guidelines.

Inputs: Type of failure/shock Isolated LV failure (e.g. STEMI-related severe/refractory CS) → Result: MCS recommendation Impella (micro-axial flow pump)（Recommended direction: Isolated LV failure, STEMI-related severe/refractory CS: DanGer Shock (2024) showed Impella CP improves survival in STEMI-CS (but with more bleeding/hemolysis/AKI/limb ischemia) → 2025 ACC/AHA upgraded to IIa (STEMI severe/refractory shock, experienced centers). IABP is not recommended routinely (IABP-SHOCK II neutral, Class III). Contraindications: mechanical aortic valve, severe AS, LV thrombus, severe peripheral vascular disease, VSD, Overall principle: At present no tMCS device has a Class I recommendation; benefit is limited to selected subgroups. Emphasize early recognition (SCAI stage + lactate + neurologic status), timely referral to experienced centers, individualized selection by failure type and center experience, and planning a weaning/escalation strategy, Basis: IABP-SHOCK II 2012; ECLS-SHOCK 2023; DanGer Shock 2024; 2023 ESC ACS guidelines; 2025 ACC/AHA ACS guidelines） Inputs: Type of failure/shock Mechanical complication (acute MR/VSD) needing a bridge → Result: MCS recommendation IABP as a bridge（Recommended direction: Mechanical complication (acute mitral regurgitation/ventricular septal rupture): IABP reduces afterload and improves coronary perfusion as a bridge before surgery/intervention; pursue definitive surgical/interventional repair as soon as possible, Overall principle: At present no tMCS device has a Class I recommendation; benefit is limited to selected subgroups. Emphasize early recognition (SCAI stage + lactate + neurologic status), timely referral to experienced centers, individualized selection by failure type and center experience, and planning a weaning/escalation strategy, Basis: IABP-SHOCK II 2012; ECLS-SHOCK 2023; DanGer Shock 2024; 2023 ESC ACS guidelines; 2025 ACC/AHA ACS guidelines）