Cardiogenic shock in pregnancy-associated spontaneous coronary artery dissection: a systematic review of invasive and mechanical circulatory support strategies

Background Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is an uncommon but severe cause of acute coronary syndrome (ACS) in women and is associated with extensive myocardial injury. P-SCAD often presents with left main involvement and rapid haemodynamic deterioration. Cardiogenic shock (CS) in this setting poses a time-critical management dilemma. SCAD pathophysiology may limit the reliability of standard ACS algorithms. Evidence guiding invasive and mechanical circulatory support (MCS) strategies in P-SCAD remains limited, underscoring the need for structured evaluation. Aim To evaluate the management strategies and outcomes of CS complicating P-SCAD, with focus on revascularisation and MCS utilisation. Methods Following PRISMA guidelines, we searched, on February 17th 2026, for original articles in PubMed, Embase, Scopus, EBSCOhost, and Cochrane from January 2006 onwards, using terms: ‘Spontaneous coronary artery dissection’ (OR ‘SCAD’ OR ‘coronary artery dissection’) AND (‘pregnancy’ OR ‘postpartum’) AND (‘cardiogenic shock’ OR ‘MCS’ OR ‘IABP’ OR ‘Impella’ OR ‘ECMO’ OR ‘LVAD’ OR ‘PCI’ OR ‘CABG’ OR ‘revascularisation.’). After screening 74 studies, 47 abstracts were reviewed, and 12 included; quality was appraised with the LEGEND tool. Results The majority of identified publications were narrative reviews, with few primary reports describing CS complicating P-SCAD. Included studies comprised 1 registry cohort, 8 case-reports , and 3 abstracts (included to minimise reporting bias if extractable clinical data present). Among 8 detailed cases, 63% occurred in the early postpartum period and 37% antepartum, consistent with registry data. Presentations frequently involved proximal territories and revascularisation strategies were heterogeneous with multiple reports of dissection propagation complicating PCI. Of the MCS therapies used, IABP was used in 3 cases, Impella in 6, and VA-ECMO in 3, with frequent escalation strategies. Devices were used sequentially or in combination. Registry data reported IABP use in 9.1% but did not disaggregate shock-specific management. Support duration ranged from 5-14 days. Maternal survival was reported in all cases however morbidity was substantial - including readmission, cardiac arrest, HFrEF and progression to cardiac transplantation (37%). Conclusion Management of CS in P-SCAD is highly individualized, often requiring escalating MCS strategies. While short-term maternal survival appears favourable, morbidity is considerable. The evidence is fragmented and largely observational with inconsistent reporting of revascularisation strategy, MCS selection, support duration and complications. This underscores the absence of structured registry-level data and standardised reporting of invasive and MCS pathways and highlights the need for dedicated multicentre registry evaluation.