Role of Mechanical Circulatory Support in Management of Acute Coronary Syndromes

Abstract

Selecting the optimal mechanical circulatory support (MCS) device and the timing of initiation for cardiogenic shock (CS) due to acute coronary syndromes (ACS) are nuanced decisions that depend on shock severity, the affected cardiac structures, patient comorbidities, and available expertise. We present three patients who presented with ACS complicated by CS due to different mechanisms and required different MCS devices. The first patient presented with acute inferior ST-segment elevation myocardial infarction (STEMI) complicated by right ventricular failure and an intracardiac right-to-left shunt, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was crucial in emergency management. The second patient presented with acute anterior STEMI complicated by CS, with a poor angiographic outcome, and a temporary left ventricular assist device (LVAD) was crucial for resuscitation after the failure of the intra-aortic balloon pump (IABP). The third patient was an elderly man with multiple comorbidities and chronic ischemic heart disease (IHD), who presented with non-STEMI (NSTEMI) complicated by cardiac arrest. Impella insertion was appropriate for short-term resuscitation and for supporting the percutaneous coronary intervention (PCI) procedure. A careful approach with early selective MCS use in the course of patients with ACS who are not responding to initial therapy is advisable, preferably under the guidance of a multidisciplinary shock team.