Stepwise escalation from temporary to durable mechanical circulatory support in post-infarction cardiogenic shock: a case report
B Milovanovic, D Kosevic, J Stefanovic Neskovic, J Miladinovic, U Radak, N Andjelkovic, N Jovicic, S BorovicAbstract
Background
Post-myocardial infarction cardiogenic shock represents the most severe manifestation of acute heart failure and is associated with persistently high mortality. Temporary mechanical circulatory support (tMCS) plays a central role in refractory shock, enabling hemodynamic stabilization and serving as a bridge-to-decision for definitive therapy.
Case Summary
A 50-year-old man was admitted with anterior ST-segment elevation myocardial infarction complicated by acute heart failure (Killip class II). Transthoracic echocardiography revealed severe left ventricular systolic dysfunction (left ventricular ejection fraction 20%). Coronary angiography demonstrated multivessel coronary artery disease with left main involvement. Despite guideline-directed medical therapy, progressive hemodynamic deterioration prompted urgent surgical revascularization. Coronary artery bypass grafting (CABG ×2) was performed. Failure to wean from cardiopulmonary bypass despite maximal pharmacological support led to implantation of an intra-aortic balloon pump (IABP) without adequate hemodynamic response, followed by escalation to veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The postoperative course was complicated by postcardiotomy cardiogenic shock and partial left ventricular thrombosis. Owing to persistent severe myocardial dysfunction and lack of recovery under tMCS, implantation of a durable left ventricular assist device (LVAD) was undertaken as a life-saving strategy.
Outcome
Following LVAD implantation, sustained hemodynamic stabilization was achieved with successful withdrawal of inotropic support. The patient was discharged in stable condition with planned multidisciplinary follow-up and rehabilitation.
Conclusion
This case underscores the importance of early recognition of irreversible myocardial dysfunction and timely transition from temporary to durable MCS within a multidisciplinary heart team approach. Stepwise MCS escalation provides critical time for appropriate therapeutic decision-making in post-infarction cardiogenic shock.