Multidisciplinary Management and Hemodynamic Rescue of Cardiogenic Shock in RCA STEMI With Severe Mitral Regurgitation

CLINICAL CONDITION: A 55-year-old man was admitted with inferior-wall ST-segment elevation myocardial infarction. He was found to have multivessel disease with a culprit lesion not amenable for revascularization, new ischemic mitral regurgitation, and cardiogenic shock, prompting the initiation of mechanical circulatory support (MCS). His course was complicated by conduction abnormalities. KEY QUESTIONS: Some questions for consideration were: 1) Which criteria guide the choice of MCS in patients with complex cardiovascular anatomy and cardiogenic shock? 2) Is coronary artery bypass grafting with concomitant mitral valve repair/replacement superior to percutaneous coronary intervention and mitral transcatheter edge-to-edge repair in patients with poor target vessels and severe mitral regurgitation? OUTCOME: After initial stabilization with intra-aortic balloon pump, the patient underwent staged percutaneous coronary intervention and mitral transcatheter edge-to-edge repair, leading to resolution of symptoms and disease. He also received a prophylactic implantable cardioverter-defibrillator in the setting of variable block and reduced left ventricular ejection fraction. TAKE-HOME MESSAGE: This case highlights the importance of multidisciplinary discussions for a patient with complex cardiovascular anatomy requiring MCS and a high level of acute care.