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Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock

Lemor A, Basir MB, Patel K, et. al. on behalf of the National Cardiogenic Shock Initiative Investigators. J Am Coll Cardiol Intv 2020;13:1171–8

Background

Potential advantages of complete revascularization vs. culprit only PCI in the setting of cardiogenic shock remains controversial in the US. To address this question, data from the National Cardiogenic Shock Initiative (NCSI), a multicenter registry of patients undergoing early MCS (Impella) in the setting of acute myocardial infarction with cardiogenic shock (AMICS). The key features of the suggested protocol include Impella unloading prior to PCI revascularization of the culprit lesion focusing on invasive hemodynamic management. This review encompasses patients with multivessel disease who underwent culprit only or multivessel PCI at the index procedure based on operator decision.

Key Points:

  • The retrospective analysis included 198 patients with multivessel (MV) coronary artery disease (CAD).
  • 126 (64%) had MV PCI; 72 (36%) had culprit only PCI.
  • Baseline characteristics of both groups were similar including age, sex, diabetes, prior PCI or CABG.
  • Patients undergoing MV PCI had a non-significant trend to worse cardiac output and lactate levels up to 12 hours.
  • By 24 hours post PCI, there were similar hemodynamic responses.
  • Survival rates were similar; MV-PCI (69.8%) while culprit PCI 65.3%, p = 0.51.
  • Acute kidney injury was not significantly different – MV-PCI 29.9% vs. culprit only PCI 34.2%; p = 0.64.
  • Similar outcomes for patients undergoing MV- PCI suggests that in selected patients, MC PCI in patients with early unloading is an acceptable approach.

A COVID -19 Perspective

  • Given the need to minimize ICU beds in the event of a COVID – 19 escalation and to minimize patient (and Staff) risk, minimizing hospital days is favorable.
  • Thus, in appropriate AMICS patients, use of an NCSI type protocol with MV-PCI, hospitalization ideally can be reduced with a 70% expected survival.