During my first on-call duties as an attending surgeon, I was once told that if I was consulted in the setting of an acute coronary syndrome, my answer should be that “the surgical treatment of acute myocardial infarction (AMI) encompasses cardiogenic shock and mechanical complications.” While essentially correct, this statement overlooked the approximately 10% of STEMI cases not amenable to percutaneous revascularization, as well as other high-risk or complex anatomical scenarios such as resuscitated ventricular arrhythmias or transient STEMI, which may also require emergent surgical management.

The recently published clinical practice guidelines originate from a purely surgical society and implicitly highlight, at least on the other side of the Atlantic, the weight that cardiovascular surgeons should carry in clinical decision-making for patients in such critical conditions. Moreover, they represent the most comprehensive update of the available evidence in an exceptionally complex clinical setting, characterized by low incidence (and therefore limited experience) combined with high clinical demand in patients facing imminent life-threatening situations.

This is a consensus document developed according to standard methodology by a panel of experts following a systematic literature review, with recommendations formulated through expert consensus. As expected, and to avoid overcomplicating the commentary, no recommendations supported by level A evidence are present. Level B-R evidence (randomized studies) is limited to three publications, mainly related to cardiogenic shock and Impella®. Recommendations are evenly distributed between class B and class C. The strongest available evidence, B-NR (nonrandomized), is scarce, with most recommendations relying on class C evidence derived from expert opinion and studies with limited data.

Below, we summarize the main recommendations, organized by clinical context:

1. General considerations:

• A multidisciplinary approach is recommended for all mechanical complications following AMI (class I).
• A stratified, consensus-based, multidisciplinary strategy should be considered, progressing from early optimal medical therapy to temporary mechanical circulatory support (tMCS) and surgical treatment when indicated, once clinical stabilization and optimization or recovery of organ dysfunction have been achieved (class I).
• tMCS may be useful in scenarios of cardiogenic shock, ventricular septal defect (VSD), and papillary muscle rupture (class IIa). Its role in free wall rupture is more controversial and should be reserved for subacute or chronic forms presenting with shock (class IIa).

2. Cardiogenic shock:

• In patients with cardiogenic shock requiring revascularization, either percutaneous or surgical, initiation of tMCS is recommended (class IIa).
• This recommendation is particularly relevant in patients with resuscitated cardiac arrest in this context (class IIa).
• In patients with AMI and ongoing ischemia who are not suitable for primary PCI or when PCI is unavailable, surgical revascularization with or without tMCS should be considered, including transfer to a cardiac surgery center (class IIa).
• tMCS should be initiated before the development of severe organ dysfunction (class I B-R).
• Escalation of vasoactive support alone is considered only a class IIb indication for tMCS.
• Rising serum lactate levels should guide initiation of tMCS (class I B-R) as a marker of peripheral hypoperfusion.
• In witnessed out-of-hospital cardiac arrest with immediate cardiopulmonary resuscitation (CPR) and a shockable rhythm, escalation to extracorporeal CPR should be considered within 60 minutes of arrest (class IIa).
• In in-hospital cardiac arrest, extracorporeal CPR should be considered in patients with a shockable rhythm who fail to achieve organ perfusion after more than 10 minutes but less than 60 minutes of CPR, provided there are no contraindications to ECMO (class IIa).
• In patients with AMI-related cardiogenic shock requiring revascularization, Impella® support is recommended (class I B-R).
• In patients supported with VA-ECMO, left ventricular unloading is recommended (class IIa).
• Initiation of tMCS is not recommended in patients with life expectancy less than 1 year due to underlying disease or comorbidities, catastrophic neurological injury, unwitnessed cardiac arrest, or documented patient or family refusal (class III).

3. Acute mitral regurgitation due to papillary muscle rupture:

• In patients presenting with shock, early initiation of tMCS (VA-ECMO), including left ventricular unloading with Impella®, should be considered as soon as shock is recognized (class IIa).
• Emergency surgery is indicated in appropriate candidates (class I).
• In patients at prohibitive surgical risk, transcatheter edge-to-edge repair may be considered in experienced centers (class IIb).

4. Postinfarction ventricular septal defect:

• Early initiation of tMCS with VA-ECMO is useful to reverse cardiogenic shock and stabilize patients before surgical repair (class IIa).
• Left ventricular unloading with Impella® carries a class IIb recommendation in this setting.
• Surgical repair should be performed once hemodynamic stabilization has been achieved (class I).

5. Free wall rupture:

• In the presence of shock, emergent surgical repair is required (class I).
• Chronic ruptures initially managed conservatively should be monitored with invasive hemodynamic assessment and frequent echocardiography (class IIb).
• Subacute or chronic forms with cardiogenic shock may be supported with tMCS prior to surgical repair (class IIb).
• Pericardiocentesis is not recommended in this setting, even in the presence of tamponade (class III).
• In patients with shock after surgical repair, initiation of tMCS with VA-ECMO or Impella® is recommended (class IIb).

6. Electrical storm:

• tMCS should be initiated in patients with refractory ventricular arrhythmias (class I).
• In patients with recurrent ventricular arrhythmias at risk of hemodynamic collapse or cardiac arrest during ablation procedures, tMCS should be considered (class IIb).
• In refractory ventricular arrhythmias occurring during percutaneous interventions or the perioperative period of cardiac surgery, tMCS may be considered (class IIb).
• In patients with persistent ventricular arrhythmias after initiation of VA-ECMO, left ventricular unloading with Impella® or alternative methods should be considered (class IIa).

7. Destination therapies:

• Before considering destination therapies such as heart transplantation or durable MCS, full recovery of organ dysfunction related to post-AMI cardiogenic shock should be achieved (class I).
• If surgical repair is not feasible or proves ineffective, destination therapies such as heart transplantation or durable MCS should be considered (class IIa).
• In patients with shock after surgical repair of mechanical complications, left ventricular assist device support as a mid-term MCS option may be considered (class IIa).
• Total artificial heart implantation may be considered in patients with severe biventricular dysfunction or anatomical contraindications to LVAD implantation when urgent heart transplantation is not an option (class IIb).

COMMENTARY:

The recently published clinical practice guidelines addressing mechanical complications and cardiogenic shock following AMI provide a valuable reference framework for our specialty, particularly regarding surgical indications and operative strategy in critically ill patients. These guidelines are led by a surgical society, the AATS, yet they adopt a distinctly clinical perspective focused on multidisciplinary decision-making, with a central role for the cardiac surgeon in determining when and how to provide mechanical support and surgical intervention in this complex clinical scenario.

They help structure clinical thinking and establish fundamental principles such as stepwise escalation of care, appropriate use of mechanical support, and proportional treatment aggressiveness, as well as careful patient selection to achieve acceptable effectiveness and efficiency. This is especially relevant in an environment where nighttime emergencies, urgency, and stress are the norm. In such circumstances, having consensus-based recommendations offers both quality assurance and professional support for clinical decision-making. In the absence of updated and comprehensive European guidance, I personally consider these recommendations valid and applicable to our reference clinical setting.

REFERENCE:

Kaczorowski DJ, Takeda K, Atluri P, Cevasco M, Cogswell R, D’Allesandro D, et al. 2025 American Association for Thoracic Surgery (AATS) Expert Consensus Document: Surgical management of acute myocardial infarction and associated complications. J Thorac Cardiovasc Surg. 2025 Nov;170(5):1327-1344. doi: 10.1016/j.jtcvs.2025.04.013.