According to the INTERMACS registry, “low profiles” define the highest severity in the spectrum of advanced heart failure.

Profile 1, the so-called “crash and burn”, refers to patients in cardiogenic shock, with critical hypotension despite inotropic support and established organ hypoperfusion.

Profile 2 includes those with declining hemodynamics and perfusion despite intravenous inotropic therapy, while profile 3 identifies patients where inotropes achieve to stabilize blood pressure and organ function, but weaning is not possible.

It is important to note that the passage from one category to another is all but infrequent, and rapid deterioration may occur in the space of minutes to hours.

These critically ill patients, beyond conventional therapy, often require mechanical circulatory support (MCS) to survive until the definitive treatment becomes available.

MCS includes extracorporeal life support (ECLS), temporary mono- or biventricular assist device (VAD), long-term VAD, and total artificial heart (TAH).

In the present chapter, we aim to outline the choice of the ideal MCS device in INTERMACS profile 1 patients.

This setting describes patients in cardiogenic shock, with a decreased cardiac function, but also at risk of developing a multiorgan dysfunction syndrome (MODS) as a result of peripheral hypoperfusion.

Once established, MODS strongly increases mortality regardless of mechanical support; hence the key to success after MCS implantation resides in patient selection, choice of timing, and optimal level of support.

In fact, according to INTERMACS registry, long-term LVAD has been associated with lower survival when offered to patients in profile 1; therefore over the years LVAD implants in the sickest patients have decreased from 40% to 14%.

One of the main reasons of poorer outcome is thought to be the higher incidence of post-implant severe right ventricular failure observed with INTERMACS profile 1. This may induce to consider and manage these patients as affected by or at high risk for biventricular failure, thus requiring a system able to replace the function of both ventricles.

Currently available devices with such characteristic, which supply full flow, at least equal to the minimum cardiac index of 2.4 l/min, are:

For these reasons, in INTERMACS profile 1 patients, where intervention is demanded within hours when not minutes, ECLS represents the first-line treatment, a “bridge-to-life” to keep the patient alive, while the optimal therapeutic strategy is determined.

ECLS can even be implanted using a percutaneous route, at the bedside under local anesthesia whenever the patient’s condition allows. This microinvasive approach provides several advantages over the techniques currently used.

First of all, simplicity, therefore it can be carried out regardless of where the patient is admitted – even in outlying hospitals – and does not necessarily require the presence of a cardiac surgeon and an anesthetist.

Secondly, implantation with local anesthesia, instead of sedation/general anesthesia, minimizes the risk of further compromising the already unstable patient’s hemodynamics.

Lastly, the minimal invasivity of this approach avoids open surgery, in particular sternotomy, thus reducing the risk of hemorrhage and infection. This is an extremely important consideration with ECLS as sepsis and bleeding are the two commonest complications.

Also, it’s worth noting how major complications, which have traditionally deterred the indications for ECLS, have decreased with the availability of newer circuits and thinner cannulae as with increasing clinical experience.