CONGRESS ABSTRACT

Cardiogenic shock remains a major clinical challenge, requiring timely recognition and intervention. Optimal management involves escalation of mechanical circulatory support (MCS), ideally within an organized hub-and-spoke network. We report the case of a 68-year-old man with ischemic heart disease due to complex coronary artery disease, with multiple percutaneous coronary interventions (PCI) of the left anterior descending artery (LAD), complicated by recurrent in-stent restenosis. In August 2025, recurrent angina led to the diagnosis of severe left main in-stent restenosis, for which surgical revascularization was attempted. Only a left internal mammary artery graft to the LAD could be performed because circumflex revascularization was not feasible. The postoperative course was complicated by cardiogenic shock, requiring urgent PCI of the left main and circumflex arteries. After initial recovery, the patient was readmitted in October 2025 from the cardiac rehabilitation ward with SCAI D cardiogenic shock, presenting with moderate left ventricular dysfunction, severe mitral regurgitation, profound hypotension and hypoperfusion resulting in hepatorenal dysfunction, secondary to acute occlusion of the LAD bypass graft. Early initiation of inotropic and vasopressor therapy combined with intra-aortic balloon pump implantation achieved partial hemodynamic stabilization. Owing to persistent instability the patient was promptly transferred to a tertiary hub center with a heart transplant program, where escalation to left ventricular unloading with Impella 5.5 resulted in marked hemodynamic improvement and recovery of end-organ function. This stabilization allowed comprehensive reassessment and planning of definitive therapy. The patient was subsequently transferred back to the referring center after 19 days of MCS and underwent successful bypass grafting to the LAD and mitral valve replacement. This case highlights the critical role of structured collaboration between centers in managing advanced cardiogenic shock. Timely escalation of mechanical circulatory support, including Impella 5.5, enables hemodynamic stabilization and effective left ventricular unloading, creating a window for comprehensive reassessment and planning of definitive therapies. Hub-and-spoke networks are therefore essential to optimize outcomes in patients with SCAI D cardiogenic shock, ensuring access to advanced therapies, including heart transplantation, when recovery is not achievable.