Outcomes of Patients with SCAD Complicated by Cardiogenic Shock Bridged with Temporary Mechanical Circulatory Support to Heart Transplant and Durable LVAD

Purpose Cardiogenic shock (CS) is a rare but potentially fatal presentation of spontaneous coronary artery dissection (SCAD). SCAD is often associated with abnormalities in other vascular beds. The safety and outcomes of patients with SCAD-CS on temporary MCS (TCMS) devices as a bridge to heart transplant (HT) and durable left ventricular assist device (LVAD) is unknown. We sought to characterize the outcomes of this unique population. Methods A comprehensive search of MEDLINE/PubMed identified 33 relevant publications meeting inclusion criteria. Data on patient characteristics, safety, and clinical outcomes was extracted. Results A cohort of 37 patients from a total of 33 case reports and series were identified. Most were female with an average age of 36 ± 6 years. SCAD-CS was the presenting manifestation in 16% of patients, while others progressed to CS later in their course. Revascularization was performed by CABG and PCI in 42% and 31% of patients, respectively. TMCS use included IABP (57%), VA-ECMO (31%), Impella (16%), surgically placed temporary VAD (8%), and biventricular support device (3%). Escalation to VA-ECMO or surgically placed temporary VAD was required in 7 patients (6 on IABP; 1 on Impella). Non-fatal TMCS complications included hemolysis (n=1, Impella) and bleeding with femoral artery dissection (n=1, VA-ECMO). Fatal complications included death from hemorrhagic shock due to accidental decannulation (n=1, VA-ECMO). Overall survival to discharge was 86%. Fourteen percent of patients received HT and 8.1% received durable LVAD. Complications related to HT include RV failure/death from a marginal donor allograft (n=1), acute graft rejection (n=1), and CMV viremia (n=1). Complications of durable VAD included pump thrombosis requiring pump exchange and HT (n=1). Other causes of death unrelated to TMCS included cardiac arrest (n=1), rupture of the right common iliac artery (n=1), and LV wall rupture (n=1). There was great variability in post-discharge outcome reporting. Conclusion Little is known about the appropriate management of SCAD-CS. To our knowledge, no prior studies have reported on outcomes of patients with SCAD-CS bridged with TMCS to HT and durable LVAD. Our data suggests acceptable outcomes in this subset of patients. Larger scale prospective studies are warranted to validate this data. Cardiogenic shock (CS) is a rare but potentially fatal presentation of spontaneous coronary artery dissection (SCAD). SCAD is often associated with abnormalities in other vascular beds. The safety and outcomes of patients with SCAD-CS on temporary MCS (TCMS) devices as a bridge to heart transplant (HT) and durable left ventricular assist device (LVAD) is unknown. We sought to characterize the outcomes of this unique population. A comprehensive search of MEDLINE/PubMed identified 33 relevant publications meeting inclusion criteria. Data on patient characteristics, safety, and clinical outcomes was extracted. A cohort of 37 patients from a total of 33 case reports and series were identified. Most were female with an average age of 36 ± 6 years. SCAD-CS was the presenting manifestation in 16% of patients, while others progressed to CS later in their course. Revascularization was performed by CABG and PCI in 42% and 31% of patients, respectively. TMCS use included IABP (57%), VA-ECMO (31%), Impella (16%), surgically placed temporary VAD (8%), and biventricular support device (3%). Escalation to VA-ECMO or surgically placed temporary VAD was required in 7 patients (6 on IABP; 1 on Impella). Non-fatal TMCS complications included hemolysis (n=1, Impella) and bleeding with femoral artery dissection (n=1, VA-ECMO). Fatal complications included death from hemorrhagic shock due to accidental decannulation (n=1, VA-ECMO). Overall survival to discharge was 86%. Fourteen percent of patients received HT and 8.1% received durable LVAD. Complications related to HT include RV failure/death from a marginal donor allograft (n=1), acute graft rejection (n=1), and CMV viremia (n=1). Complications of durable VAD included pump thrombosis requiring pump exchange and HT (n=1). Other causes of death unrelated to TMCS included cardiac arrest (n=1), rupture of the right common iliac artery (n=1), and LV wall rupture (n=1). There was great variability in post-discharge outcome reporting. Little is known about the appropriate management of SCAD-CS. To our knowledge, no prior studies have reported on outcomes of patients with SCAD-CS bridged with TMCS to HT and durable LVAD. Our data suggests acceptable outcomes in this subset of patients. Larger scale prospective studies are warranted to validate this data.