CorrigendumCorrigendum to ‘The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support’ [The Journal of Heart and Lung Transplantation, Volume 42, Issue 4, April 2023, Pages e1-e64

Task Force 1: Chairs: Alexander M. Bernhardt, MD; Jason Gluck, DO. Co-Chairs: Arthur Reshad Garan, MD, MS; Shelley Hall, MD; Awori Hayanga, MD; Ivan Knezevic, MD; Federico Pappalardo; MD; Joyce Wald, DO. Contributing Writers: Cristiano Amarelli, MD; William L. Baker, PharmD; David Baran, MD; Daniel Dilling, MD; Airlie Hogan, RN; Anna L. Meyer, MD; Ivan Netuka, MD; Minoru Ono, MD; Federico Pappalardo, MD; Gustavo Parrilla, MD; Duc Thin Pham, MD; Scott Silvestry, MD; Christy Smith, MD; Koji Takeda, MD; Sunu S. Thomas, MD, MSc; Esther Vorovich, MD, MSCE Task Force 2: Chair: Michael M. Givertz, MD. Co-Chair: Jo Ellen Rodgers, PharmD. Contributing Writers: Nana Aburjania, MD; Jean M. Connors, MD; Jasmin S. Hanke, MD; Elrina Joubert-Huebner, MD; Gal Levy, MD; Ann E. Woolley, MD, MPH Task Force 3: Chair: Hannah Copeland, MD. Co-Chairs: David L.S. Morales, MD; Amanda Vest, MBBS, MPH. Contributing Writers: Francisco A. Arabia, MD, MBA; Michael Carrier, MD, MBA; Christopher T. Salerno, MD; Benedikt Schrage, MD Task Force 4: Chair: Anita Deswal, MD, MPH. Co-Chair: Savitri Fedson, MD, MA. Contributing Writers: Larry A. Allen, MD, MHS; Cynthia J. Bither, CRNP; Shannon Dunlay, MD, MS; Paola Morejon, MD; Kay Kendall, MSW, LISW Reviewers: Michael Kiernan, MD; Sean Pinney, MD; Stephan Schueler, MD; Peter Macdonald, MD; Diyar Saeed, MD; Evgenij Potapov, MD; Tien M.H. Ng, PharmD All five chairs contributed equally. Despite medical advances, cardiogenic and pulmonary shock are associated with high mortality and morbidity.1Basir MB Kapur NK Patel K Salam MA Schreiber T Kaki A et al.Improved outcomes associated with the use of shock protocols: updates from the National Cardiogenic Shock Initiative.Catheter Cardiovasc Interv. 2019; 93: 1173-1183https://doi.org/10.1002/ccd.28307Crossref PubMed Scopus (212) Google Scholar, 2Basir MB Schreiber TL Grines CL Dixon SR Moses JW Maini BS et al.Effect of early initiation of mechanical circulatory support on survival in cardiogenic shock.Am J Cardiol. 2017; 119: 845-851https://doi.org/10.1016/j.amjcard.2016.11.037Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar, 3Vahdatpour C Collins D Goldberg S Cardiogenic shock.J Am Heart Assoc. 2019; 8e011991https://doi.org/10.1161/jaha.119.011991Crossref PubMed Google Scholar, 4Thompson BT Chambers RC Liu KD Acute respiratory distress syndrome.N Engl J Med. 2017; 377: 562-572https://doi.org/10.1056/NEJMra1608077Crossref PubMed Scopus (838) Google Scholar The availability and use of acute or temporary mechanical support devices has grown over the years, with the goal of improving patient outcomes by temporarily providing support to allow time for organ recovery or for longer term decisions including transition to durable therapies.5van Diepen S Katz JN Albert NM Henry TD Jacobs AK Kapur NK et al.Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136: e232-e268https://doi.org/10.1161/cir.0000000000000525Crossref PubMed Scopus (0) Google Scholar, 6Davies A Jones D Bailey M Beca J Bellomo R Blackwell N et al.Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome.JAMA. 2009; 302: 1888-1895https://doi.org/10.1001/jama.2009.1535Crossref PubMed Scopus (1307) Google Scholar, 7Combes A Hajage D Capellier G Demoule A Lavoue S Guervilly C Da Silva D et al.Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.N Engl J Med. 2018; 378: 1965-1975https://doi.org/10.1056/NEJMoa1800385Crossref PubMed Scopus (1124) Google Scholar A collaborative effort commissioned by the International Society of Heart and Lung Transplantation and the Heart Failure Society of America has developed this critically needed guideline for the management of patients requiring acute mechanical circulatory support (MCS). This document covers definitions of cardiogenic and pulmonary shock, medical treatment and surgical interventions, management of patients supported with temporary devices, complications, special populations, and social and ethical dilemmas. The writing groups include multidisciplinary members from both societies with a focus on diversity in gender, geography, area of expertise and level of seniority. The target audience includes cardiologists, especially interventional and advanced heart failure specialists, pulmonary and critical care specialists, intensivists, and cardiothoracic surgeons, as well as referring providers. After a review and evaluation of available literature and incorporation of the collective experience of the group, specific recommendations were assigned a class of recommendation and level of evidence. The definitions of the class of recommendation and level of evidence are listed in the Table and they are simplified into fewer categories given the paucity of high quality of evidence from randomized clinical trials of acute MCS.TableDefinitions of Class of Recommendation and Level of Evidence*Adapted from the American College of Cardiology/American Heart Association Clinical Practice Guideline Recommendation Classification system.8Class (Strength) of RecommendationClass IStrong recommendationClass IIModerate recommendation (benefit likely > risk)Class IIIHarm or no benefitLevel (Quality) of EvidenceLevel AHigh-quality evidence from 1 or more RCTs or meta-analyses of RCTsLevel BModerate quality evidence from 1 or more RCTs or meta-analyses of RCTs or well-designed observational studiesLevel CRandomized or non-randomized observational or registry studies with limitations of design or execution, or consensus of expert opinionRCTs, randomized clinical trials. Adapted from the American College of Cardiology/American Heart Association Clinical Practice Guideline Recommendation Classification system.8Halperin JL Levine GN Al-Khatib SM Birtcher KK Bozkurt B Brindis RG et al.Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2016; 133: 1426-1428https://doi.org/10.1161/cir.0000000000000312Crossref PubMed Scopus (0) Google Scholar Open table in a new tab RCTs, randomized clinical trials. This section provides contemporary definitions and outlines pathophysiology and epidemiology of cardiogenic and pulmonary shock. The severity and classification of shock is further defined along with underlying causes and hemodynamic profiles. The timing and requirements for acute MCS are detailed, including the role of shock teams, intensivists, nursing, and supportive care. Finally, specific indications, contraindications, techniques, and risks of available devices for left ventricular (LV), right ventricular (RV) and biventricular (BiV) support are reviewed. This section focuses on the management of bleeding, thrombosis, and infection. Risk factors for hemocompatibility-related adverse events are reviewed and the importance of periprocedural planning is highlighted, including formulation of anticoagulation targets and discontinuation of background therapy. Device-specific recommendations regarding periprocedural and postprocedural antithrombotic therapy are provided along with pharmacokinetic information. The management of early and late bleeding, thromboembolism, and heparin-induced thrombocytopenia (HIT) are discussed. Definitions, types, and rates of infection during acute MCS support are outlined, and prophylactic, empiric, and targeted treatment approaches recommended. The population of patients presenting with CS is heterogenous. A range of patient characteristics, comorbidities, and specific shock etiologies may alter the risks and benefits of acute MCS. This section provides guidance in the management of women, racial and ethnic minorities, patients with adult congenital heart disease (ACHD), the elderly or frail, and those with obesity or cachexia who require acute MCS. In addition, specific recommendations are provided for patients with acute fulminant and those with post cardiotomy or post–cardiopulmonary resuscitation (CPR)-related shock. Owing to marked differences in body size, clinical presentation, and available devices, pediatric patients are not covered in this guideline. Decision-making for acute MCS is typically rapid and complex, and involves a variety of invasive options, a high degree of uncertainty in outcomes, and the potential for significant patient and family suffering. This section highlights the importance of shared decision-making and informed consent while engaging necessary stakeholders. Tools to frame conversations, including use of decision aids, are discussed. The important roles of palliative care specialists, social work, ethics consultation, and local religious leaders are detailed. Finally, the concept of medical futility is defined and a decommission check-list is provided. Cardiogenic shock (CS) results from a multitude of cardiovascular (CV) disorders and remains a highly fatal (30%–60%) and morbid syndrome despite different therapeutic approaches. CS is defined as a state of tissue hypoperfusion and end organ dysfunction owing to a primary cardiac disorder with low cardiac output (CO) that can present in different stages (Society for Cardiovascular Angiography and Interventions [SCAI]/Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS]).9Baran DA Grines CL Bailey S Burkhoff D Hall SA Henry TD Hollenberg SM et al.SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.Catheter Cardiovasc Interv. 2019; 94: 29-37https://doi.org/10.1002/ccd.28329Crossref PubMed Scopus (402) Google Scholar,10Stevenson LW Pagani FD Young JB Jessup M Miller L Kormos RL et al.INTERMACS profiles of advanced heart failure: the current picture.J Heart Lung Transplant. 2009; 28: 535-541https://doi.org/10.1016/j.healun.2009.02.015Abstract Full Text Full Text PDF PubMed Scopus (521) Google Scholar Notably, invasive hemodynamics are not always required for the diagnosis of CS.3Vahdatpour C Collins D Goldberg S Cardiogenic shock.J Am Heart Assoc. 2019; 8e011991https://doi.org/10.1161/jaha.119.011991Crossref PubMed Google Scholar,5van Diepen S Katz JN Albert NM Henry TD Jacobs AK Kapur NK et al.Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136: e232-e268https://doi.org/10.1161/cir.0000000000000525Crossref PubMed Scopus (0) Google Scholar A primary cardiac insult (eg, acute myocardial infarction [AMI], acute-on-chronic heart failure (HF), fulminant myocarditis, massive pulmonary embolism) triggers CS. This initial insult results in an abrupt onset of acute or acute-on-chronic ventricular dysfunction (either systolic or diastolic) and stimulates a cascade of pathologic and compensatory reactions including systemic vasoconstriction, systemic inflammatory response syndrome, fluid retention, and impaired tissue microcirculation among others.5van Diepen S Katz JN Albert NM Henry TD Jacobs AK Kapur NK et al.Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136: e232-e268https://doi.org/10.1161/cir.0000000000000525Crossref PubMed Scopus (0) Google Scholar These mechanisms in turn result in progressive tissue hypoperfusion, coronary/myocardial hypoperfusion, and increased afterload with resultant further decrement in CO, thus propagating the death spiral of CS.5van Diepen S Katz JN Albert NM Henry TD Jacobs AK Kapur NK et al.Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136: e232-e268https://doi.org/10.1161/cir.0000000000000525Crossref PubMed Scopus (0) Google Scholar AMI is the predominant etiology of CS with ST-elevation AMI (STEMI) more culpable compared with non–ST-elevation MI.3Vahdatpour C Collins D Goldberg S Cardiogenic shock.J Am Heart Assoc. 2019; 8e011991https://doi.org/10.1161/jaha.119.011991Crossref PubMed Google Scholar,11Helgestad OKL Josiassen J Hassager C Jensen LO Holmvang L Sørensen A et al.Temporal trends in incidence and patient characteristics in cardiogenic shock following acute myocardial infarction from 2010 to 2017: a Danish cohort study.Eur J Heart Fail. 2019; 21: 1370-1378https://doi.org/10.1002/ejhf.1566Crossref PubMed Scopus (65) Google Scholar In the United States, analyses using the Nationwide Inpatient Sample (NIS) and the CATH-PCI registry, show a rising incidence of CS complicating STEMI from 6.5% in 2003 to 10.1% in 2010.12Kolte D Khera S Aronow WS Mujib M Palaniswamy C Sule S et al.Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.J Am Heart Assoc. 2014; 3e000590https://doi.org/10.1161/JAHA.113.000590Crossref Scopus (350) Google Scholar,13Wayangankar SA Bangalore S McCoy LA Jneid H Latif F Karrowni W et al.Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI Registry.JACC Cardiovasc Interv. 2016; 9: 341-351https://doi.org/10.1016/j.jcin.2015.10.039Crossref PubMed Scopus (164) Google Scholar European registry data show trends based on region and type of AMI (non-ST elevation MI vs STEMI) with incidence ranging from 5% to 10% for STEMI.11Helgestad OKL Josiassen J Hassager C Jensen LO Holmvang L Sørensen A et al.Temporal trends in incidence and patient characteristics in cardiogenic shock following acute myocardial infarction from 2010 to 2017: a Danish cohort study.Eur J Heart Fail. 2019; 21: 1370-1378https://doi.org/10.1002/ejhf.1566Crossref PubMed Scopus (65) Google Scholar,14De Luca L Olivari Z Farina A Gonzini L Lucci D Di Chiara A et al.Temporal trends in the epidemiology, management, and outcome of patients with cardiogenic shock complicating acute coronary syndromes.Eur J Heart Fail. 2015; 17: 1124-1132https://doi.org/10.1002/ejhf.339Crossref PubMed Scopus (84) Google Scholar Data surrounding CS incidence for non–AMI-related etiologies are more limited. Recent data from the NIS demonstrate a rising rate of non–AMI-related CS of 8.7 of 1000 hospitalizations compared with the previous era, with high mortality and 30-day readmission rates.15Yandrapalli S Sanaani A Harikrishnan P Aronow WS Frishman WH Lanier GM et al.Cardiogenic shock during heart failure hospitalizations: age-, sex-, and race-stratified trends in incidence and outcomes.Am Heart J. 2019; 213: 18-29https://doi.org/10.1016/j.ahj.2019.03.015Crossref PubMed Scopus (17) Google Scholar Concomitantly, there is an increase in health care costs.12Kolte D Khera S Aronow WS Mujib M Palaniswamy C Sule S et al.Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.J Am Heart Assoc. 2014; 3e000590https://doi.org/10.1161/JAHA.113.000590Crossref Scopus (350) Google Scholar,15Yandrapalli S Sanaani A Harikrishnan P Aronow WS Frishman WH Lanier GM et al.Cardiogenic shock during heart failure hospitalizations: age-, sex-, and race-stratified trends in incidence and outcomes.Am Heart J. 2019; 213: 18-29https://doi.org/10.1016/j.ahj.2019.03.015Crossref PubMed Scopus (17) Google Scholar,16Stretch R Sauer CM Yuh DD Bonde P National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis.J Am Coll Cardiol. 2014; 64: 1407-1415https://doi.org/10.1016/j.jacc.2014.07.958Crossref PubMed Scopus (337) Google Scholar Racial, gender, and age disparities exist regarding risk of developing CS. Women, Asian/Pacific Islanders, and patients over the age of 75 demonstrate a higher incidence of AMI CS.3Vahdatpour C Collins D Goldberg S Cardiogenic shock.J Am Heart Assoc. 2019; 8e011991https://doi.org/10.1161/jaha.119.011991Crossref PubMed Google Scholar,12Kolte D Khera S Aronow WS Mujib M Palaniswamy C Sule S et al.Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.J Am Heart Assoc. 2014; 3e000590https://doi.org/10.1161/JAHA.113.000590Crossref Scopus (350) Google Scholar Furthermore, significant regional and hospital heterogeneity in CS management persists. Paralleling data seen with other conditions, higher volume centers are associated with improved outcomes, and as a result regionalization of CS care using a hub-and-spoke model has been proposed.5van Diepen S Katz JN Albert NM Henry TD Jacobs AK Kapur NK et al.Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136: e232-e268https://doi.org/10.1161/cir.0000000000000525Crossref PubMed Scopus (0) Google Scholar,17Shaefi S O'Gara B Kociol RD Joynt K Mueller A Nizamuddin J et al.Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock.J Am Heart Assoc. 2015; 4e001462https://doi.org/10.1161/jaha.114.001462Crossref PubMed Google Scholar The INTERMACS profiles were developed to classify clinical severity of patients with advanced HF undergoing durable ventricular assist device (VAD) implantation.10Stevenson LW Pagani FD Young JB Jessup M Miller L Kormos RL et al.INTERMACS profiles of advanced heart failure: the current picture.J Heart Lung Transplant. 2009; 28: 535-541https://doi.org/10.1016/j.healun.2009.02.015Abstract Full Text Full Text PDF PubMed Scopus (521) Google Scholar Patients with acute CS by definition belong to INTERMACS 1 (“the crashing and burning” patient profile), potentially too sick for durable VAD therapy, with more chronic shock states being INTERMACS 2 to 4. To provide further granularity, the SCAI classification system was created and jointly supported by the American College of Cardiology, the American Heart Association, the Society of Critical Care Medicine, and the Society of Thoracic Surgeons in 2019.9Baran DA Grines CL Bailey S Burkhoff D Hall SA Henry TD Hollenberg SM et al.SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.Catheter Cardiovasc Interv. 2019; 94: 29-37https://doi.org/10.1002/ccd.28329Crossref PubMed Scopus (402) Google Scholar The SCAI classification is an easily performed, bedside assessment that stratifies patients with CS into 5 categories: stage A, the at-risk patient; stage B, the patient with beginning CS; stage C, the patient with classic CS; stage D, the deteriorating/doom patient; and stage E, the extremis patient.9Baran DA Grines CL Bailey S Burkhoff D Hall SA Henry TD Hollenberg SM et al.SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.Catheter Cardiovasc Interv. 2019; 94: 29-37https://doi.org/10.1002/ccd.28329Crossref PubMed Scopus (402) Google Scholar By design, the SCAI classification has several advantages over the INTERMACS system: the SCAI classification system accounts for changes in clinical trajectory, allows for more granularity in patient description, is specifically designed for this patient population, and can be used to optimize patient selection for future CS trial enrollment. This classification may further elucidate appropriate timing of acute MCS.18Schrage B Dabboura S Yan I Hilal R Neumann JT Sörensen NA et al.Application of the SCAI classification in a cohort of patients with cardiogenic shock.Catheter Cardiovasc Interv. 2020; 96: E213-E219https://doi.org/10.1002/ccd.28707Crossref PubMed Scopus (77) Google Scholar The hemodynamic profile of patients in CS can also be classified along similar metrics as patients presenting with acute decompensated HF (ADHF), namely, that of (1) volume status: wet vs dry and (2) systemic perfusion: warm vs cold. Patients with CS typically present as cold and wet, characterized by decreased CO with elevated filling pressures and systemic vascular resistance.5van Diepen S Katz JN Albert NM Henry TD Jacobs AK Kapur NK et al.Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136: e232-e268https://doi.org/10.1161/cir.0000000000000525Crossref PubMed Scopus (0) Google Scholar Cold and dry patients or euvolemic CS may be due to either true CS or due to volume depletion. The warm and wet CS subset refers to patients with mixed shock either owing to the well-established inflammatory response seen after an AMI or owing to concomitant infection and sepsis. Post hoc analyses from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial found that among patients with AMI-related cardiogenic shock (AMI-CS) with predominant LV shock, 64% of patients were cold and wet, 28% cold and dry, and 5% were warm and wet.19Menon V White H LeJemtel T Webb JG Sleeper LA Hochman JS The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?.J Am Coll Cardiol. 2000; 36: 1071-1076https://doi.org/10.1016/s0735-1097(00)00874-3Crossref PubMed Scopus (0) Google Scholar Analysis of blood pressure data from the same trial also revealed that despite inclusion criteria of hypotension, 5% of enrolled patients had normotensive shock, defined as a systolic blood pressure of greater than 90 mm Hg despite evidence of end-organ hypoperfusion, with hemodynamic data demonstrating higher systemic vascular resistance than the remainder of the trial cohort.19Menon V White H LeJemtel T Webb JG Sleeper LA Hochman JS The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?.J Am Coll Cardiol. 2000; 36: 1071-1076https://doi.org/10.1016/s0735-1097(00)00874-3Crossref PubMed Scopus (0) Google Scholar,20Furer A Wessler J Burkhoff D Hemodynamics of cardiogenic shock.Interv Cardiol Clin. 2017; 6: 359-371https://doi.org/10.1016/j.iccl.2017.03.006Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Interestingly, normotensive patients with CS demonstrated elevated in-hospital mortality rates compared with hypotensive patients (66% vs 43%; P = .001).19Menon V White H LeJemtel T Webb JG Sleeper LA Hochman JS The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?.J Am Coll Cardiol. 2000; 36: 1071-1076https://doi.org/10.1016/s0735-1097(00)00874-3Crossref PubMed Scopus (0) Google Scholar RV dysfunction can either be a primary insult triggering CS, that is, RV-predominant CS or the result of LV dysfunction precipitating BiV CS.20Furer A Wessler J Burkhoff D Hemodynamics of cardiogenic shock.Interv Cardiol Clin. 2017; 6: 359-371https://doi.org/10.1016/j.iccl.2017.03.006Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar RV failure (Table 1.1) is associated with poor outcomes.21Kapur NK Esposito ML Bader Y Morine KJ Kiernan MS Pham DT Burkhoff D Mechanical circulatory support devices for acute right ventricular failure.Circulation. 2017; 136: 314-326https://doi.org/10.1161/circulationaha.116.025290Crossref PubMed Scopus (150) Google Scholar In patients with AMI without CS, RV involvement is associated with increased mortality.22Hamon M Agostini D Le Page O Riddell JW Hamon M Prognostic impact of right ventricular involvement in patients with acute myocardial infarction: meta-analysis.Crit Care Med. 2008; 36: 2023https://doi.org/10.1097/CCM.0b013e31817d213d–3Crossref PubMed Scopus (0) Google Scholar,23Noguchi M Sakakura K Akashi N Adachi Y Watanabe Y Taniguchi Y et al.The comparison of clinical outcomes between inferior ST-elevation myocardial infarction with right ventricular infarction vs without right ventricular infarction.Int Heart J. 2019; 60: 560-568https://doi.org/10.1536/ihj.18-515Crossref PubMed Scopus (19) Google Scholar Secondary RV involvement in AMI-CS is noted in more than one-third of patients,21Kapur NK Esposito ML Bader Y Morine KJ Kiernan MS Pham DT Burkhoff D Mechanical circulatory support devices for acute right ventricular failure.Circulation. 2017; 136: 314-326https://doi.org/10.1161/circulationaha.116.025290Crossref PubMed Scopus (150) Google Scholar,24Lala A Guo Y Xu J Esposito M Morine K Karas R et al.Right ventricular dysfunction in acute myocardial infarction complicated by cardiogenic shock: a hemodynamic analysis of the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial and registry.J Card Fail. 2018; 24: 148-156https://doi.org/10.1016/j.cardfail.2017.10.009Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar whereas primary RV-predominant CS is rare, representing 3%–5% of the study population in the SHOCK trial and registry.25Hochman JS Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm.Circulation. 2003; 107: 2998-3002https://doi.org/10.1161/01.Cir.0000075927.67673.F2Crossref PubMed Scopus (0) Google Scholar,26Jacobs AK Leopold JA Bates E Mendes LA Sleeper LA White H et al.Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry.J Am Coll Cardiol. 2003; 41: 1273-1279https://doi.org/10.1016/s0735-1097(03)00120-7Crossref PubMed Scopus (0) Google Scholar Compared with patients with LV-predominant CS, patients with RV-predominant CS demonstrate a shorter time to diagnosis of shock, less prevalence of multivessel disease or prior MI, and a higher incidence of inferior or posterior MI.26Jacobs AK Leopold JA Bates E Mendes LA Sleeper LA White H et al.Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry.J Am Coll Cardiol. 2003; 41: 1273-1279https://doi.org/10.1016/s0735-1097(03)00120-7Crossref PubMed Scopus (0) Google Scholar RV involvement in non AMI-CS can often be seen with a variety of etiologies, most commonly with acute-on-chronic LV failure. RV-predominant shock is also seen in decompensated pulmonary hypertension, pulmonary embolism, right sided valvular disorders, RV predominant cardiomyopathies, and right HF after heart transplantation or after left ventricular assist device (LVAD) implantation.Table 1.1Hemodynamic and Echocardiographic Data that may be Supportive of RV Failure21Kapur NK Esposito ML Bader Y Morine KJ Kiernan MS Pham DT Burkhoff D Mechanical circulatory support devices for acute right ventricular failure.Circulation. 2017; 136: 314-326https://doi.org/10.1161/circulationaha.116.025290Crossref PubMed Scopus (150) Google Scholar,27Konstam MA Kiernan MS Bernstein D Bozkurt B Jacob M Kapur NK et al.Evaluation and management of right-sided heart failure: a scientific statement from the American Heart Association.Circulation. 2018; 137: e578-e622https://doi.org/10.1161/cir.0000000000000560Crossref PubMed Google ScholarCardiac index <2.2 L/min/m2 despite continuous high dose inotropes or >1 inotrope or vasopressor medication + any of the following criteria:CVP >10 mm HgCVP/PCWP ratio >0.63PAPi <2RVSWI <450 mm Hg*mL/m2RV dysfunction and/or dilation on echocardiography:TAPSE <17 mmRV systolic TDI S’ velocity <10 cm/secRVFAC <35%RV free wall longitudinal strain <–20%RV basilar diameter >42 mmRV short axis (or mid cavity) diameter >35 mmSevere RV dysfunctionCVP >15 mm HgCVP/PCWP ratio >0.8PAPi <1.5RVSWI <300 mm Hg*mL/m2ClinicalAscitesEdemaBilirubin elevationCreatinine elevationCVP, central venous pressure; FAC, fractional area change; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; RV, right ventricular; RVFAC, right ventricular fractional area change; RVSWI, right ventricular stroke work index; TAPSE, tricuspid annular plane systolic excursion; TDI, tissue Doppler imaging. Open table in a new tab CVP, central venous pressure; FAC, fractional area change; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; RV, right ventricular; RVFAC, right ventricular fractional area change; RVSWI, right ventricular stroke work index; TAPSE, tricuspid annular plane systolic excursion; TDI, tissue Doppler imaging. CS complicating AMI remains the predominant etiology accounting for up to 80% of cases.28Harjola VP Lassus J Sionis A Køber L Tarvasmäki T Spinar J et al.Clinical picture and risk prediction of short-term mortality in cardiogenic shock.Eur J Heart Fail. 2015; 17: 501-509https://doi.org/10.1002/ejhf.260Crossref PubMed Scopus (382) Google Scholar CS complicates 5%–10% of AMI and remains a deadly complication with a mortality rate of 30%–50% in contemporary registries and trials.12Kolte D Khera S Aronow WS Mujib M Palaniswamy C Sule S et al.Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.J Am Heart Assoc. 2014; 3e000590https://doi.org/10.1161/JAHA.113.000590Crossref Scopus (350) Google Scholar,28Harjola VP Lassus J Sion