Two Hearts, One Lifeline: Mechanical Circulatory Support in Pregnancy

by Ioannis (Yanni) Angelidis, MD, MSPH
Chair, SOCCA OB-CCM Task Force, Clinical Practice Committee Co-Chair SOCCA Annual Meeting Oversight Committee
University of Pittsburgh, Pittsburgh, PA

Mechanical circulatory support (MCS) in pregnancy is a rare but increasingly recognized intervention when maternal cardiogenic shock or cardiac arrest threatens both mother and fetus. Cardiovascular disease is the leading cause of maternal mortality in high-income settings, and the physiologic demands of pregnancy can unmask or exacerbate underlying cardiac conditions. In these situations, devices such as the intra-aortic balloon pump (IABP), Impella(™), left ventricular assist devices (LVADs), and extracorporeal membrane oxygenation (ECMO) provide temporary stabilization and can serve as bridges to recovery, delivery, and/or transplantation. Emerging evidence from obstetric populations underscores the importance of timely deployment and coordinated multidisciplinary care, including evolving strategies such as standby ECMO for high-risk scenarios.¹

The IABP is often considered first because of its relative simplicity and safety profile, offering modest afterload reduction and improved coronary perfusion, with experience in pregnancy largely from case series and expert consensus.² The Impella provides more robust ventricular unloading and has been used successfully in peripartum cardiogenic shock when left ventricular failure predominates, though data remain limited and decisions must be individualized.³ LVADs, traditionally reserved for advanced heart failure, have been implanted in select pregnant or postpartum patients as durable therapy or bridges to transplant; case reports and series describe successful maternal support through delivery and postpartum recovery when anticoagulation and obstetric planning are carefully coordinated.^4,5 ECMO, particularly veno-arterial ECMO, offers both cardiac and respiratory support and is invaluable in refractory shock or cardiac arrest; reports in obstetric cohorts suggest encouraging maternal survival alongside meaningful fetal outcomes when instituted promptly and managed by experienced teams.^1,6,7

Clinical indications for MCS in pregnancy include peripartum cardiomyopathy, massive pulmonary embolism, amniotic fluid embolism, severe preeclampsia with cardiac decompensation, and decompensation of congenital or acquired heart disease. Each case presents unique challenges: anticoagulation increases bleeding risk during delivery, cannulation sites can complicate obstetric procedures, and the gravid uterus alters anatomy, affecting device placement and hemodynamics. These complexities highlight the need for tightly integrated care among cardiology, anesthesiology, critical care, obstetrics, and neonatology, with pre-planned delivery strategies and contingency pathways for maternal and fetal emergencies.^1,6,8

Recent data highlights both promise and limitations. A systematized review of standby ECMO in obstetric patients outlines practical criteria for pre-emptive preparation, team activation, and cannulation strategies tailored to maternal physiology and delivery timing, emphasizing that readiness can shorten time to support and potentially improve outcomes.¹ Focused reviews of peripartum cardiogenic shock synthesize device selection by hemodynamic phenotype—left-sided failure favoring Impella or IABP, biventricular or combined respiratory failure favoring VA-ECMO—and stress the role of early recognition and escalation.³ Case reports further humanize the impact of these devices: for example, a young woman at 27 weeks with cardiogenic shock after viral illness survived with sequential VA-ECMO, IABP, and Impella support, allowing delivery and maternal recovery despite complications². Parallel population studies on cardiac arrest during delivery hospitalization provide context for preparedness, resource allocation, and the potential role of advanced support when conventional measures falter.^7,8

Looking forward, research gaps remain. Optimal device selection by gestational age and hemodynamic profile, strategies to minimize fetal compromise during maternal support, anticoagulation protocols around neuraxial anesthesia and delivery, and long-term maternal and neonatal outcomes require ongoing research efforts. Creating combined national registries within SOCCA, SCA, SOAP could help further investigation. Greater awareness, standardized activation pathways (including standby ECMO where appropriate), and timely initiation of support can save lives. Equally important is keeping the human core of this work in view—meeting families at the crisis point with clarity, compassion, and coordinated expertise—so that technology serves not only physiology but possibility.^1,3,6 

References

1. Marudo D, et al. Standby Extracorporeal Membrane Oxygenation Use in Obstetric Patients: A Systematized Review. 

2. van der Zande JA, Blel D, Kauling RM, et al. Implications of mechanical circulatory support devices in a pregnant woman with cardiogenic shock. Exploration of Cardiology. 2025;3:101244.

3. Botti G, Thirunavukarasu S, Ziviello F, Chieffo A. Peripartum cardiogenic shock and mechanical circulatory support. Interventional Cardiology. 2023;18:e28.

4. Saito S, Westaby S, Katsumata T, et al. Left ventricular assist device in pregnancy: case report and review. J Heart Lung Transplant. 2004;23(5):605–608.

5. Joubert J, et al. Pregnancy in women with left ventricular assist devices: outcomes and management. Eur Heart J. 2019;40(12):1005–1012.

6. Extracorporeal Life Support Organization (ELSO). Guidelines related to ECMO in pregnancy. Ann Thorac Surg. 2017;104(2):620–626.

7. Mhyre JM, Tsen LC, Einav S, et al. Cardiac arrest during hospitalization for delivery in the United States, 1998–2011. Anesthesiology. 2014;120(4):810–818.

8. Ford ND, DeSisto CL, Galang RR, et al. Cardiac arrest during delivery hospitalization: a cohort study. Ann Intern Med. 2023;176(4):472–479.