Optimal Management of a Patient With Stemi Complicated by Refractory Cardiogenic Shock Through Successful Collaboration Between Spoke and Hub Centers

Abstract Male, 51 y–o. STEMI (5/4/23) → PCIp on proximal LAD without procedural complications. Post–procedure BP 120/30 mmHg, HR 85 bpm. Critical stenoses remained on Circumflex (CFx)–Marginal Obtuse (MO).In the post–procedure observation, the patient experienced two episodes of Ventricular Fibrillation (VF),treated with DC–Shock, and cardiogenic shock,prompting urgent coronary angiography.The decision was made for ultrasound–guided right femoral arterial access and pre–procedural implantation of Impella CP smart–assist device in the left ventricle.During coronary angiography, hyperacute stent thrombosis in the proximal LAD was observed.Manual thrombus aspiration followed by Angiojet Spiroflex thromboaspiration partially improved flow (TIMI 1).Due to evidence of critical stenosis (likely plaque shift),a DES was implanted in the ostio–proximal segment of the LAD.Revascularization was completed on the MO and CFx–MO axis. TIMI 3 flow achieved.Echocardiographic control confirmed proper Impella CP placement,estimated LVEF10%,normal right sections.Impella CP flow 3.9 L/min post–procedure.Due to acute pulmonary edema during the procedure,the patient was sedated,intubated,and transferred to the ICU.On April 6, 2023, refractory cardiogenic shock persisted despite circulatory support with Impella and adrenaline 0.25