Review Article Mechanical Circulatory Support Options in Patients With Aortic Valve Pathology Jeans Miguel Santana, MD * , Adam A. Dalia, MD, MBA, FASE y , Melinda Newton, MS, RRT-ACCS z , Dominic V Pisano, MD * , Sarah Eapen, MD x , Masashi Kawabori, MD x , Jamel Ortoleva, MD || ,1 * Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA y Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA z Department of Respiratory Care, Tufts Medical Center, Boston, MA x CardioVascular Center, Cardiac Surgery, Tufts Medical Center, Boston, MA || Department of Anesthesiology and Perioperative Medicine, TuftsMedical Center, 800 Washington Street, Ziskind Building 6th Floor, Boston, MA02111 Mechanical circulatory support (MCS) is used in cardiogenic shock for periprocedural hemodynamic stability in high-risk patients and to support patients with symptomatic coronary artery disease. Depending on the MCS type, oxygenation and ventilation, in addition to increasing blood pressure by augmenting blood flow, can be achieved. MCS typically follows a failure of less invasive maneuvers or intolerance to them, such as significant ventricular arrhythmia burden from inotropic support. MCS options include intra-aortic balloon pump, transvalvular percutaneous left ventricular assist devices, venoarterial extracorporeal membrane oxygenation, and surgically implanted left ventricular assist devices. The number of MCS options has increased, and this has made the decision-making process complicated. MCS decision-making is complex, even in patients without valvular pathology. The presence of aortic valve (AV) abnormalities, such as aortic stenosis, aortic insufficiency, replaced AVs, or AV masses, adds even further to the challenge of selecting the appropriate support strategy. In this narrative review, a concise review of MCS options and the special considerations for various AV pathologies are presented. Ó 2022 Elsevier Inc. All rights reserved. Key words: MCS; Mechanical Circulatory Support; Aortic Valve; Aortic Insufficiency Mechanical circulatory support (MCS) is used in cardio- genic shock for periprocedural hemodynamic stability in high- risk patients and to support patients with symptomatic coro- nary artery disease. 1-4 Depending on the type, MCS can sup- port oxygenation and ventilation in addition to increasing blood pressure by augmenting the forward flow of blood or draining blood from one location and reinfusing it to another. Escalation to MCS in end-stage heart failure generally follows a trial of less invasive maneuvers, such as volume optimization with diuresis, intravenous inotropic support, and noninvasive or invasive positive pressure ventilation. 5,6 MCS can follow a failure of these less invasive maneuvers or intolerance to them, such as significant ventricular arrhythmia burden from inotropic support. The number of MCS options hasincreased, and this has made the decision-making processcomplicated. Many factors are consideredin the decision to support patients, including age, noncardiac organ dysfunction, suitability for advanced therapy options, and, above all else, patient goals of care. The options for patients in cardiogenic shock are mono- or biventricular support (Fig. 1 and 2; Table 1). 5,6 It is impor- tant to understand the effects of various MCS options on left ventricular (LV) loading conditions; for an excellent pictorial description, see the work by Lo and Magnus. 7 Valvular abnormalities, particularly of the aortic valve (AV), are an especially important consideration in MCS decisions, as certain devices cannot be used because of 1 Address correspondenceto Department of Anesthesiology and Perioperative Medicine, TuftsMedical Center, 800 Washington Street, Ziskind Building 6th Floor, Boston, MA02111. E-mail address: jortoleva@tuftsmedicalcenter.org (J. Ortoleva). https://doi.org/10.1053/j.jvca.2022.04.010 1053-0770/Ó 2022 Elsevier Inc. All rights reserved. Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 33183326 Contents lists available at ScienceDirect Journal of Cardiothoracic and Vascular Anesthesia journal homepage: www.jcvaonline.com