Extracorporeal life support for acute coronary syndrome complicated with cardiogenic shock requiring PCI: The impact of the shock team on outcomes

Objectives: To verify the impact on intra-hospital survival of the "Shock Team" in the decision to use Veno-arterial ECMO (VA-ECMO) as support in patients with acute coronary syndrome (ACS) in cardiogenic shock (CS), requiring percutaneous revascularization (PCI). Methods: Consecutive patients who from July 2013 to September 2020, presented to our Center for SCA and CS candidates for primary PCI, supported with VA-ECMO, were considered. The Shock Team is composed of the Hemodynamic Cardiologist, Clin- ical Cardiologist, Anesthesiologist, Cardiac Surgeon and Perfusionist. Over the years, the shared pre- or intra- procedural decision of how to mechanically support the circulation or not in patients with CS has been im- plemented. The retrospective analysis of consecutive patients has as primary end-point the frequency of Shock Team training, from the analysis of the conditions in which VA-ECMO was implanted, i.e. semi-elective (ECLS - Extracorporeal Life Support) or emergency (ECPR - Extracorporeal Cardio-Pulmonary Resuscita- tion), followed by the rate of weaning and survival from VA-ECMO. Results: Twenty-three patients (19 males, median age 63 years, range 59-66 years) were supported with femoral- femoral VA-ECMO. The Shock Team was formed in 11 cases. When Shock Team was formed (Group 1), VA- ECMO was implanted as ECLS in 7/11 cases, in the remaining as ECPR. In Group 2 (no pre-procedure Shock Team consultation), VA-ECMO was implanted as ECPR in 11/12 cases (92%) and intra-procedure. Pre- or intra-procedural IABP was implanted in all patients in Group 2. In Group 1, intra-hospital survival was 9/11 cases (82%) and in Group 2 3/12 cases (25%), in most of the latter with no possibility of weaning. Conclusions: In our case series, periprocedural Shock Team in patients with CS, allowed the establishment of mechanical support to the circulation in a semi-elective manner, with successful PCI and was associated with high survival. In contrast, in those in whom VA-ECMO is implanted as ECPR due to lack of shared decision, high intra-hospital mortality is observed. We therefore recommend in patients with ACS and CS the presence and consultation of the pre-procedural Shock Team.