The management of acute heart failure and acute cardiogenic shock has evolved dramatically over the past decades with marked improvements of many methodologies， from pharmacotherapeutic strategies to surgical intervention.  This morning Dr. Mark Berger Anderson from the University of Medicine and Dentistry of New Jersey， USA introduced some of these changes， there impact on patient outcome， and cardio-functional improvements， as well as specific strategies for the relief of cardiac shock.  His clinical experience and research demonstrated benefits of bi-ventricular support to improve hemodynamic recovery and overall improve patient outcomes and indicate a potential paradigm shift in the management of cardiogenic shock.

    While many methodologies have seen modest improvements across the spectrum， ventricular assist device (VAD) improvements in particular， especially with regard to cardiac load alleviation and a trend toward non-invasiveness have improved patient outcomes considerably.  According to the American Heart Association’s Health Statistical Update， approximately 40% of all patients hospitalized for cardiogenic shock related to myocardial infarction (MI) and cardiotomy are unresponsive to IABP or ionotrope therapy.  Patients in this cohort are considered candidates for assist devices however few actually receive devices due variations in recoverability.  Acute heart failure， on the other hand， is more likely recoverable for reasons including a younger patient population and better end organ status.  Additionally， characteristics of acute heart failure which differ significantly from chronic heart failure include the amount of bi-ventricular involvement and the need for emergent circulatory support.  Moreover， acute cardiogenic shock varies with regard to intensity of ventricular dysfunction and degree of hemodynamic compromise.

    Dr. Anderson emphasized that for sustainable cardiac recovery for cardiogenic shock post-MI， timing is critical and greatly impact the patient’s chances for survival but suggested we re-ask what we should also be looking at during cardiac recover in addition to mere survival.  Ventricular unloading in post-MI patients raises other issues including improvements in myocardial blood flow， reduction in re-perfusion injury， and limitation of the infarct size， and recovery issues of stem cell recruitment， mitigation of apoptosis， and creating an intramyocardial environment which enhances cell proliferation. 
Noting his clinical experience in the USA， Dr. Anderson emphasized the importance of relieving hemodynamic load of the heart during episodes of cardiogenic shock.  Ventricular rest can create an environment to limit further myocyte loss and encourage self repair although timing of shock onset to VAD implant is critical.  A recent study of acute-MI patients in 42 centers in the US implanted with ABIOMED AB5000 showed remarkable recovery of native heart function  who where implanted with the Impella 5.0 miniature LVAD showed marked hemodynamic improvements and remarkable reduction of mortality， a 24% reduction from anticipated mortality.  In the recent past VAD intervention has been considered a bridge to transplantation and patient management has focused on “door-to-balloon” time as an important factor decreasing negative outcomes.  Dr. Anderson suggests a paradigm shift is in order， focusing instead on “door-to-unloading” time where the recovery achieved while the load on the heart is removed may instead be a bridge to recovery.