Cardiogenic shock with severe LV systolic dysfunction: aggressive myocardial salvage holds the key

Despite impressive strides in the management of acute coronary syndromes (ACS), cardiogenic shock (CS) with severe LV systolic dysfunction (LVSD) continues to be associated with very high mortality and morbidity. CS most frequently results from compromised blood flow and subsequent dysfunction of large myocardial volume. Management strategies are aimed at early restoration of perfusion to the ischemic myocardium. We present our experience employing an aggressive management strategy for CS, including emergent percutaneous coronary intervention (PCI) with adjunctive inotropic and IABP support. From 1/2000 to 1/2003, we performed PCI in 80 patients (39% female; mean age 67) presenting with CS, 78% of them presenting within 24 hours of an acute MI. Co-morbidities included age >70, 45%; diabetes, 65%; prior MI, 24%. We treated 96 lesions: 9% were left main lesions, 58% in the LAD distribution; 60% were ostial/proximal. Mean global LVEF was 31.8%. Inotropic support was used in all patients, IABP in 89%. Results: Procedural success was achieved in 74 patients (92.5%). Three patients had ventricular fibrillation during the procedure, successfully terminated. There were 2 acute reclosures (2.5%) necessitating re-PCI. Three of the 6 unsuccessful revascularization patients died during hospitalization (3.8%); 1 went to urgent CABG surgery. Mean IABP time was 16.2 hours; mean hospital stay was 2.77 days. At 1-year follow-up, 10.8% had undergone revascularization. Mortality was 6.3%; all deaths occurred within the first 3 months following PCI. Mean global LVEF rose to 39.22% (p = 0.000^∗). The incidence of ER visits/ hospitalization for heart failure was 4.1%. Major cardiac event-free survival was 76.3%. Conclusions: Our series demonstrates that successful PCI is associated with encouraging outcomes in the treatment of CS: (1) Procedural success and acute survival are excellent following successful revascularization and effective restoration of TIMI 3 coronary flow, with low in-hospital events. (2) At 1-year follow-up, cardiac morbidity is low with favorable event-free survival. (3) There is significant improvement in global LV systolic performance at 1 year, suggesting effective myocardial salvage may have contributed to improved clinical outcomes. (4) Adjunctive IABP hemodynamic support appears to be integral to the improved outcomes. Thus, aggressive emergent revascularization strategies can improve the dismal outcomes historically reported with CS and severe LVSD in ACS.