This protocol is the standard of care in our institution.
1. Insertion of the PVAD (e.g., Impella CP)
<ol>
	<li>Obtain common femoral access over the lower half of the femoral head under fluoroscopic and ultrasound guidance using a micro-puncture needle9,10. Position the micro-puncture sheath and obtain an angiogram of the femoral artery to confirm appropriate arteriotomy location11.</li>
	<li>Insert a 6 Fr sh...

Minimizing the Risks and Complications of PVAD (Table 2) 
The hemodynamic benefits of PVAD can be significantly neutralized if complications from large-bore access occur, such as major bleeding and acute limb ischemia28,29. It is thus essential to minimize the risk and complications of the device.
In order to decrease access site complications and reduce the number of access attempts, ultrasound and fluoroscopic g...

Cardiogenic shock (CS) is defined as persistent hypotension (systolic blood pressure &#60;90 mmHg for &#62;30 minutes, or the need for vasopressors or inotropes), end-organ hypo-perfusion (urine output &#60;30 mL/h, cool extremities or lactate &#62; 2 mmol/L), pulmonary congestion (pulmonary capillary wedge pressure (PCWP) &#8805; 15 mmHg) and decrease cardiac performance (cardiac index &#60;2.2 <img alt="Equation 1" fo:break-after="column" src="/files/ftp_upload/62110/62110eq01v2.jpg" />)1,2 due to a primary cardiac disorder. Acute myocardial infarction (AMI) is the most common cause of CS3. CS occurs in 5-10% of AMI and historically has been associated with significant mortality3,4. Mechanical circulatory support (MCS) devices such as intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (PVAD), extracorporeal membrane oxygenation (ECMO) and percutaneous left atrial to aortic devices are frequently used in patients with CS5. Routine use of IABP has demonstrated no improvement in clinical outcomes or survival in AMI-CS1. Given the poor outcomes associated with AMI-CS, the difficulties in conducting trials in AMI-CS, and the negative results of IABP use in AMI-CS, clinicians are increasingly looking to other forms of MCS.
PVADs are increasingly utilized in patients with AMI-CS6. In this article, we will focus our discussion primarily on the Impella CP, which is the most common PVAD used currently6. This device utilizes an axial flow Archimedes-screw pump which actively and continuously propels blood from the left ventricle (LV) into the ascending aorta (Figure 1). The device is most frequently placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery. Alternatively, it can be implanted through an axillary or transcaval access when necessary7,8.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>4 Fr-018-10 cm Silhouette Stiffened Micropuncture Set</td>
			<td>Cook</td>
			<td>G48002</td>
			<td>Microvascular access</td>
		</tr>
		<tr>
			<td>5 Fr Infiniti Pigtail Catheter</td>
			<td>Cordis</td>
			<td>524-550S</td>
			<td>pigtail catheter</td>
		</tr>
		<tr>
			<td>Impella CP Intra-cardiac Assist Catheter</td>
			<td>ABIOMED</td>
			<td>0048-0003</td>
			<td>Impella catheter kit</td>
		</tr>
	</tbody>
</table>

utilizing percutaneous ventricular assist devices in acute myocardial infarction complicated by cardiogenic shock

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices (PVADs) are used for the treatment of cardiogenic shock in an effort to improve hemodynamics. Impella is currently the most common PVAD and actively pumps blood from the left ventricle into the aorta. PVADs unload the left ventricle, increase cardiac output and improve coronary perfusion. PVADs are typically placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery when feasible. In cases of severe peripheral arterial disease, PVADs can be implanted through an alternative access. In this article, we summarize the mechanism of action of PVAD and the data supporting their use in the treatment of cardiogenic shock.

Table 1 shows the safety and efficacy of PVAD implantation35,36,37,38,39,40.
Optimizing PVAD Outcomes 
PVADs are a resource-heavy intervention that requires significant experience and expertise to optimize outcomes. The following best practices should be consi...

Watch this Scientific Journal Video about Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock at JoVE.com

Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Percutaneous ventricular assist devices are increasingly being utilized in patients with acute myocardial infarction and cardiogenic shock. Herein, we discuss the mechanism of action and hemodynamic effects of such devices. We also review algorithms and best practices for the implantation, management and weaning of these complex devices.

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices ...