Short-Term Percutaneous Mechanical Circulatory Support: No Promise Without Positioning!

Short-term percutaneous mechanical circulatory support by a micro-axial flow pump is increasingly used to support the left ventricle in cardiogenic shock. After a correct indication and placement, appropriate device management in the cardiac intensive care unit is vital to ensure optimal pump function and adequate hemodynamic support. A key element hereby is a correct percutaneous ventricular assist device (pVAD) position. This review explains how an optimal left-sided pVAD position can be achieved and maintained, focusing on a correct insertion depth and rotational angle. Useful imaging techniques, placement and replacement maneuvers, and monitoring options through the console are discussed. The frequently encountered problem of mal-rotation towards the mitral valve, which may cause suction alarms, hemolysis, aortic regurgitation and inadequate hemodynamic support is explained. Finally, a practical bedside approach to assess pVAD position and discern suction alarms due to mal-positioning from hemodynamic problems is proposed.