Culprit only versus complete revascularization: Insights from the detroit cardiogenic shock initiative category: Complex PCI, restenosis, left main & multi-vessel intervention

Background: The optimal revascularization strategy in patients presenting with acute myocardial cardiogenic shock (AMICS) remains under debate. We sought to determine the clinical outcomes of AMICS patients based on revascularization strategy in the Detroit Cardiogenic Shock Initiative (DCSI) prospective registry. Methods: A total of 50 consecutive patients enrolled in the DCSI - the pilot study for the National Cardiogenic Shock Initiative (NCSI) - at five centers in the metro Detroit area between July 2016 and May, 2017 were included. All patients underwent PCI and a mutually agreed-upon protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS was used by all participating centers. Results: Multi-vessel obstructive CAD occurred in 32 (64%) of patients, with mean age of 65±11 years and in-hospital survival of 81% (26/ 32). Among these, 50% (16/32) underwent complete revascularization (CR) and 50% (16/32) underwent incomplete revascularization (IR). Baseline demographics were similiar in both groups. Compared to IR cohort, the CR group had significantly shorter door-to-balloon times, less number of diseased vessels, lower proportion of shock on admission, and lower heart rates, with no other statistically significant differences in pre-procedural hemodynamics or perfusion parameters. Hemodynamic and perfusion parameters at 24 hours of mechanical hemodynamic support (MCS) were similar, with trend towards worse paramters in the CR group. There were no statistically significant differences in the number of successful PCI, survival during PCI, need for MCS upgrade, duration of MCS and total hospital length of stay. There was a trend towards improved survival in patients who underwent IR as compared to those who underwent CR, survival: 94% vs 69% (p=0.07), respectively. Conclusion: In patients presenting with AMICS with multivessel CAD undergoing PCI, despite robust MCS, a strategy of incomplete revascularization was associated with significant reduction in postprocedural vasopressor requirements, and a trend towards improved hemodynamic and perfusion parameters as well as overall survival - findings that corroborate observations from the CULPRIT SHOCK trial