Interview with Dr. Alexander Bernhardt: Escalation and De-escalation Strategies  

Alexander Bernhardt, M.D., discusses insertion, escalation, de-escalation, and weaning of mechanical circulatory support (MCS) devices in patients with cardiogenic shock. Dr. Bernhardt is the first author of “Differential Utilization of Impella Devices, ECMO and Combined Therapies as Escalation and De-escalation Strategies.” This is one of eight articles published in the European Heart Journal supplement “From Patient Selection to Escalation Strategies: Mechanical Circulatory Support in Cardiogenic Shock.”

“In this publication we try to give some guidance on when and how we have to implant devices, what kind of devices we have to implant, and when to de-escalate and wean these devices,” Dr. Bernhardt explains. Device selection is based on metabolic demand and right heart catheter (RHC) parameters. “The main principle we try to address is ‘hit hard and early’ to overcome the initial cascade of cardiogenic shock.”

Dr. Bernhardt explains escalation as, “having a device in place and the patient is in need of another device, or in need of a device which is more powerful or adds, for example, oxygenation/decarboxylation to the patient.” He provides the example of a patient supported with Impella CP® for cardiogenic shock who remains in shock and needs additional oxygenation. This patient could be escalated by adding VA ECMO to Impella CP, a combination known as ECMELLA. Or this patient may require longer duration support and have support escalated from Impella CP to an axillary inserted Impella 5.5® that provides more flow and allows the patient to ambulate while on support. Dr. Bernhardt also discusses escalation to biventricular support with either ECMELLA or both left- and right-sided Bipella devices.

Dr. Bernhardt explains that de-escalation occurs when, for example, a patient who is receiving biventricular support from two devices is de-escalated to only one device, or a less invasive device, which is associated with fewer complications. In contrast, weaning is more of a process of reducing the flow of a device over time, rather than changing devices.