When the Heart Needs a Machine: Mechanical Support Options

When medications, inhaled therapies, and careful fluid management (detailed in The Step-by-Step Plan to Strengthen the Right Heart) are not enough to keep the blood flowing, the right heart is said to be in refractory failure ^[1]. In these critical moments, the medical team may recommend Mechanical Circulatory Support (MCS). These are external or internal pumps that take over the physical work of the heart, allowing the right ventricle to rest and, hopefully, heal ^[2][3].

The Two Main Types of Support

There are two primary ways doctors can mechanically support the right heart. The choice depends on whether the lungs also need help and how much total support the body requires.

• RVADs (Right Ventricular Assist Devices): These are specialized pumps like the Impella RP or ProtekDuo ^[4][5].

  • How they work: These devices use a thin tube (cannula) to pull blood out of the right heart and pump it directly into the pulmonary artery (the pipe to the lungs). This effectively “jumps” the blood over the failing right ventricle ^[6].
  • The Focus: These are generally used for isolated right heart failure where the left heart and lungs are still doing their jobs relatively well ^[4].

• VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenation): This is the most complete form of life support.

  • How it works: Blood is taken out of the body, run through an artificial lung (oxygenator) to add oxygen and remove carbon dioxide, and then pumped back into the body ^[7].
  • The Focus: This is used when both the heart and the lungs are failing, or when the entire circulatory system is in deep shock ^[8].

The Concept of “Bridge to Recovery”

In the setting of heart surgery, these devices are most often used as a bridge to recovery. This means the doctors believe the heart muscle is not permanently dead, but is “stunned” or “exhausted” from the surgery ^[3].

• Healing Time: By letting the machine do the heavy lifting for a few days or weeks, the swelling in the heart can go down, and the muscle fibers can regain their strength ^[4].
• The Goal: The ultimate goal is to slowly “wean” the machine—turning down its speed over several days—to see if the patient’s own heart can take back the workload ^[9].

Understanding the Risks

While these machines are life-saving, they are also highly invasive and carry significant risks that the team must manage 24/7.

• Bleeding: Because the blood is being pushed through plastic tubes at high speeds, patients must often take blood thinners to prevent clots. This significantly increases the risk of bleeding ^[4][5].
• Infection: Every tube entering the body is a potential “doorway” for bacteria. Infectious complications are a major concern in the ICU ^[10][11].
• Blood Trauma (Hemolysis): The spinning blades of the pumps can sometimes “bruise” or break red blood cells as they pass through ^[12].
• Limb Issues: In VA-ECMO, the large tubes in the leg can sometimes block blood flow to the foot (limb ischemia). The team monitors the pulses in the feet constantly to prevent this ^[13].

Making the Decision

Deciding to move to mechanical support is a heavy moment for any family. However, research suggests that early initiation—starting the support before other organs like the kidneys and liver begin to fail—is often associated with better chances of a successful recovery ^[14][15]. These devices are not a sign that the team has “given up,” but rather that they are using every tool available to give the heart the best chance to mend.

For information on what the long-term outlook holds once the patient starts coming off the machine, read The Long Road: Prognosis and the Path to Healing.