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

Abstract

<h3>Purpose</h3> 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. <h3>Methods</h3> A comprehensive search of MEDLINE/PubMed identified 33 relevant publications meeting inclusion criteria. Data on patient characteristics, safety, and clinical outcomes was extracted. <h3>Results</h3> 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. <h3>Conclusion</h3> 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.