Physiology-guided integration of full left ventricular unloading and coronary revascularization in acute myocardial infarction-related cardiogenic shock

Background Mechanical LV unloading and coronary revascularization are cornerstone therapies in cardiogenic shock, however, evidence supporting a physiology-guided strategy integrating the extent of revascularization in acute myocardial infarction–related cardiogenic shock (AMI-CS) is limited Purpose To assess the association between physiology-guided full left ventricular unloading and revascularization strategy, with complete (CR) versus partial (PR), and myocardial recovery and native heart survival (NHS) in patients with AMI-CS Methods We analyzed a registry of patients with AMI-CS treated between January 2022 and June 2024. The primary endpoint was a composite of NHS (freedom from death, transplant, or durable LVAD at discharge) and myocardial recovery, defined as left ventricular ejection fraction ≥ 45% at ≥1 year Results Among 179 patients with AMI-CS, 127 required Impella 5.5 for full LV unloading; 65 underwent CR and 62 PR. Despite greater angiographic burden in the PR group, lesion complexity was higher in the CR group (SYNTAX score median 29 [IQR 21–32] vs 25 [IQR 19–28]). Baseline LVEF was comparable between groups (27.6 ± 12.9% vs 25.4 ± 12.1%). The CR group demonstrated significantly higher LVEF at discharge (38.8 ± 13.4% vs 30.5 ± 9.2%) and at 1 year (49.8 ± 15.4% vs 34.7 ± 13.6%), mean difference 15.1% (95% CI 7.8–22.4; p< 0.001). The primary endpoint was achieved in 50.8% of the CR group versus 22.6% of the PR. At 1 year, CR in the setting of full LV unloading was associated with achievement of the primary endpoint. In the adjusted analysis, CR was independently associated with native heart survival and myocardial recovery (OR 3.15, 95% CI 1.62–6.10; p=0.001). Escalation to ECMO and new RRT were similar between groups (15.4% vs 17.7% and 31.0% vs 30.6%, respectively), despite a higher baseline renal risk profile in the CR group. Conclusion In patients with AMI-CS, a physiology-guided strategy integrating full unloading with CR during the index hospitalization was associated with greater NHS and myocardial recovery. These findings support an integrative shock care approach in which mechanical unloading and comprehensive myocardial perfusion are aligned to optimize long-term outcomes.