When a Failing Heart Needs a Mechanical Assist: How MCS Is Changing High-Risk Cardiac Care
Patients with severely weakened heart function, extensive coronary artery disease or cardiogenic shock were once often considered too high-risk for complex interventions.
For some patients with severe heart disease, the biggest challenge is not finding a procedure but making the heart strong enough to withstand it.
Patients with severely weakened heart function, extensive coronary artery disease or cardiogenic shock were once often considered too high-risk for complex interventions. Advances in Mechanical Circulatory Support (MCS) are changing that equation, giving specialist cardiac teams another option to temporarily support circulation while they treat the underlying problem.
MCS devices such as the Impella heart pump and extracorporeal membrane oxygenation (ECMO) can provide temporary support in carefully selected patients. While Impella assists the heart's pumping function, ECMO can provide broader support to the heart and lungs in critically ill patients.
Prof. Dr Babu Ezhumalai, Senior Consultant – Interventional Cardiology, Structural & Endovascular Interventions at MGM Healthcare, Chennai, says the change has been significant over the course of his career. “When I got trained in interventional cardiology nearly two decades ago, many patients with severely impaired heart function or cardiogenic shock had very few treatment options because the procedural risk was simply too great. Looking back, advances in Mechanical Circulatory Support (MCS), intravascular imaging, calcium-modification techniques, and critical care have completely transformed that landscape.”
According to Dr Ezhumalai, MCS is particularly relevant when conventional support is no longer sufficient. “The intra-aortic balloon pump (IABP) has been an important mechanical support device for many years and continues to play a valuable role in selected patients by improving blood flow to the heart and reducing its workload. However, its level of circulatory support is limited.
Patients with profound cardiogenic shock, extremely low blood pressure, or those who experience cardiac arrest often require much greater haemodynamic support. This is where newer technologies such as Impella and ECMO become invaluable.”
When an 83-year-old was considered for high-risk angioplasty
The potential of these technologies can be seen in carefully selected high-risk patients.
As a proctor for complex high-risk indicated percutaneous coronary intervention (CHIP-PCI), Dr Ezhumalai has treated patients with severely calcified coronary disease, including some who had previously been considered unsuitable for bypass surgery.
One particularly challenging case involved an 83-year-old man who had recently suffered a heart attack. Angiography showed severe disease involving the left main coronary artery and all three major coronary vessels. His arteries were heavily calcified and his heart's pumping capacity had fallen to around 30%.
The patient underwent high-risk angioplasty with temporary Impella support. Advanced intravascular imaging and calcium-modification techniques were used to restore blood flow.
His symptoms subsequently improved, he returned to his normal daily activities and follow-up showed improvement in heart function.
“Cases like these demonstrate how modern support technologies are expanding treatment possibilities for patients who would previously have been considered inoperable or too high-risk,” Dr Ezhumalai added.
When seconds matter
The role of MCS can become even more critical in cardiogenic shock, when the heart is unable to pump enough blood to maintain adequate circulation to vital organs.
Dr Ezhumalai recalls a 69-year-old patient who arrived at the emergency department with a massive heart attack, extremely low blood pressure and critical blockages involving the left main coronary artery and multiple other vessels.
During emergency treatment, the patient suffered cardiac arrest and profound circulatory collapse. After cardiopulmonary resuscitation restored his heartbeat, his circulation remained critically unstable.
The medical team escalated support from an intra-aortic balloon pump to ECMO, allowing the circulation to be stabilised before complex coronary angioplasty and stent implantation were completed.
The patient required prolonged intensive care but was eventually weaned from ECMO and discharged. Follow-up showed recovery of heart function, with his ejection fraction improving to 53%.
“This case illustrates why timing is so important in cardiogenic shock. When conventional support is no longer sufficient, recognising the need to escalate to advanced mechanical circulatory support at the right time can be critical to giving the patient a chance of recovery.”
Technology needs a team
The growing availability of MCS does not mean the technology can be used independently of specialist expertise. Impella and ECMO require trained interventional cardiologists, cardiac anaesthetists, intensivists, perfusion specialists, nurses and round-the-clock critical-care support.
Large-bore vascular access and careful patient selection are also essential.
“Advanced Mechanical Circulatory Support technologies such as Impella and ECMO require far more than specialised equipment alone. Successful outcomes depend on highly trained interventional cardiologists, experienced cardiac anaesthetists, intensivists, perfusion specialists, skilled nursing teams, and round-the-clock critical care support working together seamlessly.”
Dr Ezhumalai believes advanced MCS will gradually become available at more centres in India, but stresses that expansion must be accompanied by the expertise required to use it safely.
“At present, these technologies are available mainly in select tertiary-care centres with the expertise and infrastructure required to manage complex, high-risk patients. As experience grows and more centres develop these capabilities, I believe access to advanced mechanical circulatory support will gradually expand across India.
Ultimately, the goal is not simply to make advanced technology more widely available, but to ensure that it is used appropriately, safely, and by experienced multidisciplinary teams in patients who are most likely to benefit.”
His experience with MCS also extends beyond adult cardiac care. A case involving an eight-year-old boy following heart transplantation, who required repeated ECMO support and emergency PCI, was subsequently published in IHJ Cardiovascular Case Reports in 2019. Dr Ezhumalai was among the authors of the report.
The evolution of MCS, therefore, is not simply about newer machines replacing older ones. For carefully selected patients, it represents another layer of support that can give cardiac teams time to restore blood flow, stabilise circulation and, in some cases, create a path to recovery or transplantation.
