Background: Cardiogenic shock (CS) is a frequent presentation of anterior ST-elevation myocardial infarction (STEMI); however, data regarding disease progression and outcomes in inferior STEMI complicated by CS are scarce. The present study aims to analyze the prevalence, patterns of disease progression, and outcomes of inferior STEMI-CS. Methods: The INSTINCT (Inferior ST-elevation myocardial Infarction complicated by Cardiogenic shock) Registry retrospectively included consecutive patients who developed CS following inferior STEMI treated at three centers in Italy from 2015 to 2023. Data regarding CS stage according to the Society of Cardiovascular Angiography and Interventions (SCAI) upon diagnosis of shock and during disease progression and in-hospital outcomes were collected. Patients were defined “worsening” (WPs) if the SCAI stage increased. Results: A total of 130 patients developed CS after inferior STEMI and were included in the analysis, the mean age was 69.8 ± 12.4 years, and 31.5% were female. The rate of in-hospital mortality was 22.3%; predictors of in-hospital mortality were cardiopulmonary resuscitation (CPR) > 20 min or refractory cardiac arrest (CA) (OR [CI]: 9.67 [3.17–29.51]), persistently low systolic blood pressure (SBP) (OR [CI]: 12.91 [2.47–68.82]), and increase in lactates (OR [CI]: 3.53 [1.42–7.87]) during medical management. Twenty (15.4%) patients experienced worsening CS; WPs had a significantly higher rate of in-hospital mortality (13 [65%] vs. 15 [13.6%], p < 0.001), major bleeding (4 [20%] vs. 7 [6.4%], p = 0.044), and mechanical circulatory support weaning failure (7 [35%] vs. 3 [2.7%], p = 0.032). Conclusions: The in-hospital mortality rate of inferior STEMI complicated by CS was 22.3%. Predictors of in-hospital mortality included prolonged CPR, persistently low SBP, and elevated lactates. Progression through SCAI stages was rare but associated with significantly higher mortality and complication rates.

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis across a wide range of patients.¹ Despite technological advances, conduction disturbances remain frequent, and many patients require permanent pacemaker (PPM) implantation.^2,3 Conventional right ventricular pacing (RVP) may induce electrical and mechanical dyssynchrony, promoting left ventricular dysfunction and heart failure.⁴ Left bundle branch area pacing (LBBAP) offers a more physiological activation by engaging the native conduction system.⁵ Although beneficial in non-TAVI populations,^6,7 its role after TAVI is not well defined. This study compares outcomes of LBBAP vs. RVP in post-TAVI patients requiring PPM implantation.

Cardiogenic shock (CS) is a complex, life-threatening syndrome characterized by inadequate tissue perfusion due to impaired cardiac function. Acute myocardial infarction (AMI) and acute decompensated heart failure are the leading causes, with mortality remaining high despite advances in revascularization and supportive care. The Society for Cardiovascular Angiography and Interventions (SCAI) classification allows risk stratification and guides clinical decision making by capturing the spectrum of shock severity. Percutaneous mechanical circulatory support (pMCS) devices, such as the intra-aortic balloon pump (IABP) and Impella, aim to stabilize hemodynamics by augmenting cardiac output and unloading the left ventricle. However, randomized trials and meta-analyses have not demonstrated a consistent survival advantage of Impella over IABP, while reporting higher rates of bleeding and vascular complications. Landmark trials, including ECLS-SHOCK and DanGer, have provided conflicting results, likely reflecting differences in baseline severity and timing of device implantation. Veno-arterial extracorporeal membrane oxygenator (VA-ECMO) offers full cardiopulmonary support but increases left ventricular afterload, potentially worsening myocardial injury. Combined strategies such as ECPELLA (Impella + VA-ECMO) or ECMO + IABP may mitigate left ventricle (LV) overload and improve bridging to recovery or advanced therapies, although evidence remains largely observational and complication rates are considerable. In right-sided or biventricular failure, tailored options (e.g., Impella RP, Bi-Pella) guided by invasive hemodynamics may be required. Current evidence suggests that pMCS benefits are limited to carefully selected subgroups, underscoring the importance of early diagnosis, prompt referral, and individualized intervention. Robust randomized data are still needed to define the optimal role of pMCS in AMI-related CS.

Background: Little is known about stroke volume index (SVi) change and its prognostic implication in patients with low‐flow aortic stenosis (AS) undergoing aortic valve replacement (AVR) and conflicting results are present in literature. The aim of this study was to evaluate the postoperative change in SVi and its impact on outcomes in patients with low‐flow severe AS undergoing AVR. Methods: Retrospective observational study of a high‐volume tertiary care center including consecutive patients with low‐flow (SVi ≤ 35 mL/m ² ) severe AS who underwent AVR (either surgical or transcatheter) with available comprehensive pre‐ and post‐AVR echocardiographic assessment. Post‐AVR SVi improvement was defined as an increase ≥ 15% from baseline, while SVi normalization was defined as post‐AVR SVi > 35 mL/m ² . A up to 36‐month follow‐up was conducted and the study primary endpoint was the composite of all cause‐mortality and hospitalizations for heart failure. Results: One‐hundred‐fifty‐one patients (mean age 80 ± 8 years, 53.6% female) were included. After AVR, SVi improved by > 15% in 51 (33.8%) and normalized in 51 (33.8%) patients. At a median follow‐up of 17 (7−32) months, 62 (52.6%) patients reached the primary composite endpoint. SVi improvement, but not SVi normalization, was associated with better survival free from the primary endpoint (log rank p = 0.02 and 0.056, respectively). Multivariate analysis confirmed that both SVi improvement and its absolute change per mL/m ² unit carried a better prognosis (adj. HR 0.51 [0.28–0.91, p = 0.02] and 0.97 (0.94–0.99), p = 0.016, respectively). Conclusions: In patients with low‐flow AS undergoing AVR, early post‐procedural SVi increase has beneficial prognostic significance. These findings highlight the importance of post‐AVR hemodynamic assessment and may help refine risk stratification in this vulnerable population.