Multilevel Venous Obstruction in Patients with Cardiac Implantable Electronic Devices.

Background and Objectives: The nature of multilevel lead-related venous stenosis/occlusion (MLVSO) and its influence on transvenous lead extraction (TLE) as well as long-term survival remains poorly understood. Materials and Methods: A total of 3002 venograms obtained before a TLE were analyzed to identify the risk factors for MLVSO, as well as the procedure effectiveness and long-term survival. Results: An older patient age at the first system implantation (OR = 1.015; p < 0.001), the number of leads in the heart (OR = 1.556; p < 0.001), the placement of the coronary sinus (CS) lead (OR = 1.270; p = 0.027), leads on both sides of the chest (OR = 7.203; p < 0.001), and a previous device upgrade or downgrade with lead abandonment (OR = 2.298; p < 0.001) were the strongest predictors of MLVSO. Conclusions: The presence of MLVSO predisposes patients with cardiac implantable electronic devices (CIED) to the development of infectious complications. Patients with multiple narrowed veins are likely to undergo longer and more complex procedures with complications, and the rates of clinical and procedural success are lower in this group. Long-term survival after a TLE is similar in patients with MLVSO and those without venous obstruction. MLVSO probably better depicts the severity of global venous obstruction than the degree of vein narrowing at only one point.

Transvenous Lead Extraction in Pediatric Patients　- Is It the Same Procedure in Children as in Adults?

BACKGROUND: Cardiac implantable electronic devices (CIED) are very rare in the pediatric population. In children with CIED, transvenous lead extraction (TLE) is often necessary. The course and effects of TLE in children are different than in adults. Thus, this study determined the differences and specific characteristics of TLE in children vs. adults.Methods and Results: A post hoc analysis of TLE data in 63 children (age ≤18 years) and 2,659 adults (age ≥40 years) was performed. The 2 groups were compared with respect to risk factors, procedure complexity, and effectiveness. In children, the predominant pacing mode was a single chamber ventricular system and lead dysfunction was the main indication for lead extraction. The mean implant duration before TLE was longer in children (P=0.03), but the dwell time of the oldest extracted lead did not differ significantly between adults and children. The duration (P=0.006) and mean extraction time per lead (P<0.001) were longer in children, with more technical difficulties during TLE in the pediatric group (P<0.001). Major complications were more common, albeit not significantly, in children. Complete radiographic and procedural success were significantly lower in children (P<0.001). CONCLUSIONS: TLE in children is frequently more complex, time consuming, and arduous, and procedural success is more often lower. This is related to the formation of strong fibrous tissue surrounding the leads in pediatric patients.

Lead Extraction in Children and Young Adults: When is the Best Time for Lead/System Replacement?

The best strategy for lead management in children is a matter of debate, and our experiences are limited. This is a retrospective single-center study comparing difficulties and outcomes of transvenous lead extraction (TLE) implanted ich childhood and at age < 19 years (childhood-implanted-childhood-extracted, CICE) and at age < 19 (childhood-implanted-adulthood-extracted, CIAE). CICE patients-71 children (mean age 15.1 years) as compared to CIAE patients (114 adults (mean age 28.61 years) were more likely to have VVI than DDD pacemakers. Differences in implant duration (7.96 vs 14.08 years) appeared to be most important, but procedure complexity and outcomes also differed between the groups. Young adults with cardiac implantable electronic device implanted in childhood had more risk factors for major complications and underwent more complex procedures compared to children. Implant duration was significantly longer in CIAE patients than in children, being the most important factor that had an impact on patient safety and procedure complexity. CIAE patients were more likely to have prolonged operative duration and more complex procedures due to technical problems, and they were 2-3 times more likely to require second-line or advanced tools compared to children, but the rates of clinical and procedural success were comparable in both groups. The difference between the incidence of major complications between CICE and CIAE patients is very clear (MC 2.9 vs 7.0%, hemopericardium 1.4 vs 5.3% etc.), although statistically insignificant. Delay of lead extraction to adulthood seems to be a riskier option than planned TLE in children before growing up.

Cardiac tamponade as an inherent but potentially nonfatal complication of transvenous lead extraction: Experience with 1126 procedures performed using mechanical tools.

INTRODUCTION: Cardiac tamponade (CT) is one of the most common and dangerous complications of transvenous lead extraction (TLE). So far, however, there has been little discussion about the problem. METHODS: We analyzed the occurrence of CT in a group of 1226 patients undergoing TLE at a single reference center between June, 2015 and February, 2021. Using standard mechanical devices as first-line tools, a total of 2092 leads had been extracted. RESULTS: CT occurred in 18 patients (1.47%): due to injury to the wall of the right atrium in 14 patients (1.14%) and other cardiac walls in four patients (0.33%). Younger patient age at first implantation, female gender, high left ventricular ejection fraction (LVEF), lower New York Heart Association class, low Charlson comorbidity index, longer implant duration, and the number of previous procedures related to cardiac implantable electronic devices (CIED) are important patient-related risk factors for CT. Significant procedure-related risk factors include the number of extracted leads, extraction of atrial leads and longer dwell time of extracted leads. Intraoperative transoesophageal echocardiography (TEE) provides a lot of information about pulling on various cardiac structures and is able to detect a very early phase of bleeding to the pericardial sac. As a result of implementing best practices guidance in performing extraction procedures and close collaboration with cardiac surgeons that allowed immediate rescue intervention in our series of 18 CT cases, there were no procedure-related deaths (mortality 0%). CONCLUSIONS: The need for rescue surgery due to CT has no influence on clinical and procedural success. Early diagnosed (TEE monitoring) and properly managed CT does not generate any additional risk in short- and long-term follow-up after TLE.

The role of cardiac surgeon in transvenous lead extraction: Experience from 3462 procedures.

INTRODUCTION: The professional society guidelines recommend that transvenous lead extraction (TLE) operating teams collaborate closely with cardiac surgeons in the management of life-threatening complications. METHODS: We assessed the role of cardiac surgeons participating in 3462 TLE procedures at a high-volume center between 2006 and 2021. The roles for cardiac surgery in TLE can be categorized into five areas: emergency surgical interventions for the management of cardiac laceration and severe bleeding (1.184%), cardiac surgery complementing partially successful TLE or vegetation removal (0.693%), delayed surgical treatment of TLE-related tricuspid valve dysfunction (0.751%), epicardial pacemaker implantation through sternotomy during emergency, complementing or delayed surgical interventions (0.607%), and delayed epicardial lead implantation (0.491%). RESULTS: Isolated damage to the wall of the right atrium was the most common cause of cardiac tamponade (53.66% of emergency surgeries) followed by injury to the right ventricle and vena cava (both 7.317%). CONCLUSIONS: Emergency cardiac surgery for the management of severe hemorrhagic complications is still the most common treatment option. The remaining areas include surgery complementing partially successful TLE: repair of tricuspid valve or epicardial ventricular lead placement to achieve permanent cardiac resynchronization. The experience at a single high-volume TLE center indicates the necessity of close collaboration with the cardiac surgeons whose roles appear broader than the mere surgical standby. Mortality in patients who survived cardiac surgery during TLE does not differ from the survival of other patients after TLE without complications requiring surgical intervention.

Blockage of extracorporeal circulation during emergency surgery for fulminant infective endocarditis.

A 37-years-old man with a history of alcohol abuse and pancreatitis, presented to the emergency department with a 1-week history of progressively worsening dyspnoea with a fever up to 39°C. Echocardiography revealed bicuspid aortic valve with additional mobile structure and perforation of leaflet with acute aortic regurgitation. Due to rapidly deteriorating condition of the patient, a decision about immediate surgery was made. In the operating room, cardiac arrest in the asystole mechanism occurred. Extracorporeal circulation was turned on during direct heart massage. After opening of the aorta, the circulation was blocked by total clogging of the arterial line filter by fibrine deposits. The oxygenator was replaced which resulted a break in extracorporeal circulation lasting about 10 min. Patients survived surgery and was discharged after 6 week antibiotic therapy.

Risk Factors and Long-Term Survival of Octogenarians and Nonagenarians Undergoing Transvenous Lead Extraction Procedures.

INTRODUCTION: Transvenous lead extraction (TLE) has become a frequently used tool for the management of complications related to pacemakers, implantable cardiac defibrillators and cardiac resynchronization therapy devices. However, it is still a matter of debate whether the lead extraction procedure is a safe treatment choice in the elderly. METHODS: We collected the clinical information from 3,810 patients undergoing TLE in 2 high-volume centers (Poland and Italy) between 2006 and 2017. We tested risk factors, effectiveness, safety and long-term survival in 3 groups of patients: those aged 80-89.99 years, ≥90 years and 30-79.99 years. RESULTS: Lower BMI, lower levels of hemoglobin and more comorbidities characterized the patients, whose ages ranged from 80 to 89.99 years. Those aged ≥90 years most often had single-chamber pacemakers. Octogenarians and nonagenarians were more often undergoing TLE due to infectious indications (57.19 and 74.29 vs. 45.35% in younger individuals). Lead age and the number of leads extracted were comparable in the 3 groups. In octogenarians, leads were more often removed using standard extraction techniques: simple traction and mechanical dilatators, whereas in nonagenarians TLE was more complex. The duration of the procedure was shorter in older patients, while clinical and procedural effectiveness was similar to that in younger individuals. The rate of major complications related to TLE did not differ between octogenarians and younger subjects (2.0 vs. 1.38%, p = ns), and the number of procedure-related risk factors was smaller in older people. Nonagenarians did not develop any major complication related to TLE. Long-term mortality after TLE was similar among octogenarians and nonagenarians (39.67 and 40.00%) but higher than in younger patients (24.41; p < 0.001 and 0.05). CONCLUSIONS: Lead extraction procedures appear effective and safe in octogenarians and nonagenarians, comparable to younger individuals. Procedure-related risk in the elderly is not associated with most of the typical risk factors encountered in younger subjects, but only with the higher number of pacemaker, implantable cardiac defibrillator and cardiac resynchronization therapy device procedures before TLE. Long-term survival after TLE was found to be similar among octogenarians and nonagenarians being about 60% at over 3 years of follow-up. Age alone should not be considered a risk factor for the occurrence of major complications or procedure-related death, and therefore it should not prevent candidacy for TLE.

Ultrasound-guided imaging for vagus nerve stimulation to facilitate cardioneuroablation for the treatment of functional advanced atrioventricular block.

We present a case study article demonstrating successful implementation of ultrasound guided extra cardiac vagus nerve stimulation during cardioneuroablation. To our knowledge it is first published description of this technique, as most ECVS are done in the internal jugular vein bulb area. This method allows for reduction of fluoroscopy time, and most importantly reproducible vagus nerve capture especially after full bi-nodal (sinus and atrioventricular) cardioneuroablation when stimulation of vagus nerve may not give any effect in the heart. This article includes a case study with "dual component" atrioventricular block, where functional component is cured with cardioneuroablation, but structural (PR elongation) remains after procedure.

A new approach to the continuous monitoring of transvenous lead extraction using transesophageal echocardiography-Analysis of 936 procedures.

AIMS: The usefulness of transesophageal echocardiographic (TEE) monitoring for transvenous lead extraction (TLE) procedures is still controversial. The purpose of the current study was to present new TEE values in detecting invisible events in fluoroscopy and preventing the development of dangerous complications. METHODS: From 2015 to 2019, a total of 1026 procedures were performed in single TLE center. In total, 1108 leads had been extracted with a mean lead dwell time of 115.8 ± 77.6 months. Continuous TEE was used in 936 patients with a mean age of 67.1 ± 14.4 years. RESULTS: Preprocedure examination revealed looped leads in 181 (19.3%) patients, dry cardiac perforation in 151 (16.1%), lead-to-lead adhesion in 172 (18.4%), lead adhesion to the myocardium in 317 (33.9%), and vegetations in 119 (12.7%) patients. Intra-procedural TEE demonstrated pulling on the atrial wall, ventricular wall, or tricuspid valve in 380 (40.5%), 235 (25.1%), and 78 (8.3%) patients, respectively. Acute tamponade requiring sternotomy occurred in 11 (1.1%) patients. Migration of vegetation or connective tissue fragments were seen in 69 (7.3%) and 111 (11.8%) patients, respectively. After procedure, TEE was helpful in navigating an implantation, a new lead in 97 (10.3%) patients, and removing the remnants of lead/silicone insulation in 50 (5.3%) patients. CONCLUSION: Real time transesophageal echocardiography for the guidance of transvenous lead extraction informs the operator about the danger of manipulations close to delicate cardiac structures and whether immediate modification to the plan of lead removal is necessary in order to prevent the occurrence of unwanted events.

Transvenous lead extraction procedures in women based on ESC-EHRA EORP European Lead Extraction ConTRolled ELECTRa registry: is female sex a predictor of complications?

AIMS: Female sex is considered an independent risk factor of transvenous leads extraction (TLE) procedure. The aim of the study was to evaluate the effectiveness of TLE in women compared with men. METHODS AND RESULTS: A post hoc analysis of risk factors and effectiveness of TLE in women and men included in the ESC-EHRA EORP ELECTRa registry was conducted. The rate of major complications was 1.96% in women vs. 0.71% in men; P = 0.0025. The number of leads was higher in men (mean 1.89 vs. 1.71; P < 0.0001) with higher number of abandoned leads in women (46.04% vs. 34.82%; P < 0.0001). Risk factors of TLE differed between the sexes, of which the major were: signs and symptoms of venous occlusion [odds ratio (OR) 3.730, confidence interval (CI) 1.401-9.934; P = 0.0084], cumulative leads dwell time (OR 1.044, CI 1.024-1.065; P < 0.001), number of generator replacements (OR 1.029, CI 1.005-1.054; P = 0.0184) in females and the number of leads (OR 6.053, CI 2.422-15.129; P = 0.0001), use of powered sheaths (OR 2.742, CI 1.404-5.355; P = 0.0031), and white blood cell count (OR 1.138, CI 1.069-1.212; P < 0.001) in males. Individual radiological and clinical success of TLE was 96.29% and 98.14% in women compared with 98.03% and 99.21% in men (P = 0.0046 and 0.0098). CONCLUSION: The efficacy of TLE was lower in females than males, with a higher rate of periprocedural major complications. The reasons for this difference are probably related to disparities in risk factors in women, including more pronounced leads adherence to the walls of the veins and myocardium. Lead management may be key to the effectiveness of TLE in females.

To abandon or not to abandon: Late consequences of pacing and ICD lead abandonment.

INTRODUCTION: The increasing number of cardiac implantable electronic device complications represents a current problem. Abandoned leads are difficult to manage, even because indications to transvenous lead extraction (TLE) cannot be generalized. The aim of the study was to assess the late consequences of previous abandoned leads. METHODS: We did a retrospective analysis of clinical data from 3,810 patients undergoing TLE in two high-volume centers (Poland and Italy) in the years 2006-2017. In order to evaluate the effects of lead abandonment, the patients were divided into a group of 582 (15.3%) subjects with abandoned leads (AL) and a group of 3,228 (84.7%) subjects with functional leads (FL). RESULTS: Infective indications to TLE were predominant in the AL group (61.34% vs 43.4%; P < 0.001). AL was associated with a higher number of leads per patient, longer lead dwell times, more frequent venous occlusion, higher probability of intracardiac lead abrasion, and tricuspid regurgitation (P < 0.001 for all factors). The presence of AL was connected with more frequent technical complications of TLE (odds ratio [OR] 1.617; confidence interval [CI] 1.412-1.852; P = 0.000), lower procedural success rate (OR 0.270; CI 0.199-0.363; P = 0.000), and with higher mortality rate during 3.518 years of follow-up [hazard ratio 1.286; 95% CI (1.062-1.558), P = 0.010]. CONCLUSIONS: Presence of previously abandoned leads was associated with the risk of device infections, technical problems during subsequent lead extraction, dysfunction of tricuspid valve, and worse long-term outcomes.

Risk of Complications and Survival of Patients Dialyzed with Permanent Catheters.

Background and Objectives: An increase in the incidence of end-stage renal disease (ESRD) is associated with the need for a wider use of vascular access. Although arteriovenous (A-V) fistula is a preferred form of vascular access, for various reasons, permanent catheters are implanted in many patients. Materials and Methods: A retrospective analysis of clinical data was carried out in 398 patients (204 women) who in 2010-2016 were subjected to permanent dialysis catheters implantation as first vascular access or following A-V fistula dysfunction. The factors influencing the risk of complications related to vascular access and mortality were evaluated and the comparison of the group of patients with permanent catheter implantation after A-V fistula dysfunction with patients with first-time catheter implantation was carried out. Results: The population of 398 people with ESRD with mean age of 68.73 ± 13.26 years had a total of 495 permanent catheters implanted. In 129 (32.6%) patients, catheters were implanted after dysfunction of a previously formed dialysis fistula. An upward trend was recorded in the number of permanent catheters implanted in relation to A-V fistulas. Ninety-two infectious complications (23.1%) occurred in the study population in 65 patients (16.3%). Multivariate analysis showed that permanent catheters were more often used as the first vascular access option in elderly patients and cancer patients. Mortality in the mean 1.38 ± 1.17 years (min 0.0, max 6.70 years) follow-up period amounted to 50%. Older age and atherosclerosis were the main risk factors for mortality. Patients with dialysis fistula formed before the catheter implantation had a longer lifetime compared to the group in which the catheter was the first access. Conclusion: The use of permanent catheters for dialysis therapy is associated with a relatively high incidence of complications and low long-term survival. The main factors determining long-term survival were age and atherosclerosis. Better prognosis was demonstrated in patients after the use of A-V fistula as the first vascular access option.

Effectiveness, safety, and long-term outcomes of non-powered mechanical sheaths for transvenous lead extraction.

Aims: To analyse the effectiveness, safety and long-term outcomes of conventional non-powered mechanical systems for transvenous lead extraction (TLE) performed by experienced first operators. Outcomes were assessed according to lead location and type of operating room in which the procedure was performed. Methods and results: Data from 2049 patients (mean age: 65 years), with infectious (40%) or non-infectious (60%) indications, were analysed over a mean of 3.37 (±2.29) years. A total of 3426 leads were extracted; and, overall, 95% full procedural, 4% partial procedural, and 98% clinical success were demonstrated. Within the patient cohort, 1.8% (37/2049) experienced major complications, with cardiac tamponade being predominant (30/37). Cardiac tamponade was identified as the main cause of mortality, as well as the cause of all procedure-related deaths (6/2049; 0.3%). Cardiac tamponade occurred in 1.8% of atrial and 0.3% of right ventricular lead extractions, with fatal tamponade reported in 9% of atrial, 40% of ventricular, and 67% of coronary sinus lead extractions. No association between lead location and cardiac tamponade-related mortality was observed; however, lead location did affect the success of pericardiocentesis. The cardiac tamponade-related mortality rate was 37% when TLE was performed in an electrophysiology laboratory. No deaths were reported when the procedure was performed in a cardiac surgery or hybrid operating room. Long-term survival was improved when TLE was performed due to non-infectious indications, rather than pocket infection or lead-related endocarditis (P < 0.001). Conclusion: Using conventional non-powered mechanical sheaths, TLE was effective even in patients at high risk of complications.

Lead-related infective endocarditis: factors influencing the formation of large vegetations.

AIMS: The presence of intracardiac lead vegetations (ILV) is one of the important criteria for diagnosis of lead-related infective endocarditis (LRIE). The objective of the present study was to evaluate risk factors of ILV and their impact on vegetation size. METHODS AND RESULTS: Clinical data of 500 patients with LRIE undergoing transvenous lead extraction in 2006-15 were retrospectively analysed. The study population consisted of 352 patients with the presence of vegetations (giant, >3 cm; large, 2.0-2.9 cm; moderate-sized, 1.0-1.9 cm; and small, <1 cm) and 148 patients without ILV. We identified risk factors for vegetation occurrence and ILV size. Intracardiac lead vegetations were found more frequently in younger patients (P < 0.05), slightly more often in women (P = 0.084), and less commonly in patients with atrial fibrillation (P < 0.05). Intracardiac lead vegetation occurred significantly more frequently in patients with intracardiac lead abrasion (OR 2.373; 95% CI [1.497-3.765]; P < 0.001) and much less frequently in the concomitant presence of pocket infection (PI) (OR 0.127; 95% CI [0.074-0.218]; P < 0.00). Large vegetations were significantly more common in patients with renal failure (RF) (P < 0.001), heart failure (P < 0.001), implantable cardioverter defibrillator (P < 0.05), and loops of the leads (P < 0.001). CONCLUSION: Intracardiac lead abrasion is one of the most common factors influencing the occurrence of ILV. Metabolic disorders in patients with RF, heart failure, defibrillation leads, and loops of the leads were found to contribute to the formation of large vegetations. In LRIE patients, ILVs were less frequently detected in the presence of concomitant PI, indicating a different mechanism of LRIE development in patients with and without vegetations.

Impact of ICD lead on the system durability, predictors of long-term survival following ICD system extraction.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) systems are considered as having higher risk of complication and shorter durability but reasons of this multifactorial phenomenon remain unclear. We aimed to analyze this problem in population of patients with ICD leads referred for lead extraction (TLE). METHODS: We have compared TLE indications, procedural results, and defined the long-term outcomes of TLE in patients with ICD/CRT-D devices (n  =  482, ICD (+)) with lead extractions in patients with standard pacemakers (n  =  1,402, ICD (-)). Demographic, clinical characteristics, and procedural outcomes were ascertained from single, primary operator registry. Long-term survival data were provided by the National Health Fund. RESULTS: The ICD (+) subgroup had a significantly higher incidence rate of either infective or noninfective indications for TLE. The clinical success rate of extraction was 99.2% in ICD (+) versus 97.4% in ICD (-) (P  =  0.05) at a complication rate of 1.04% versus 2.14% (NS), respectively. In the median follow-up of 3.39 years, 142 patients from the ICD (+) subgroup and 303 from the ICD (-) subgroup died. The highest mortality rate of 41.1% was observed in the ICD (+) subgroup with infective indications. Infection, renal failure, diabetes, and age were the multivariate factors associated with increased mortality in the ICD (+) subgroup. CONCLUSION: ICD leads remain more vulnerable, with respect to mechanical failure and their propensity to infection, in comparison to pacing leads. Their TLE is very effective at least complication rate, when performed by a highly skilled and experienced operator. However, long-term mortality after their TLE is high and is affected mostly by infections or patient-related factors.

[Analysis of the incidence and causes of repeated surgical interventions in patients with early complications electrotherapy - 1 center experience from the period 2012-2015].

Baclground: Due to increasing number of patients treated by cardiac implantable electronic devices we observe increasing number of complications after these procedures Material and methods: We analysed causes of early surgical revision of implantable devices connected with 1673 procedures of implantation (871 procedures) or exchange (802 procedures) of pacing systems (PM), cardioverter-difibrillators (ICD) and resynchronisation systems (CRT) in one local centre of electrotherapy in years 2012 to 2015. We characterised risk factors and its influence on encountered complications. Results: In analysed period 72 reinterventions after implantations or exchanges of PM/ICD/CRT were performed. Main causes of early complications were: lead malfunction (2.5%), including the dislodgement of the leads in 1.9%, pocket hematoma (1.4%) and other abnormalities of the pocket (0.4 %), including pocket infections in 0.2%. The most important risk factors of early complications were often implantations of the leads with passive fixation and anticoagulation therapy in perioperative period. Conclusions: The knowledge of the early complications after implantations and exchanges of PM/ICD/CRT should improve the safety of procedures through more often used of the leads with active fixation and properly preparation of the patients requering the antithrombic therapy.

[Risk factors and treatment of patients with ST-segment elevation myocardial infarction with cardiogenic shock].

Aim: To assess risk factors and prognosis in patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS) in Poland. Methods: Data from The Polish Registry of Acute Coronary Syndromes (PL-ACS) were analysed in 2008-2012. A total of 57400 consecutive STEMI patients included. The results of treatment and prognosis of patients with and without CS were compared. An additional analysis of the prognosis of men and women with CS was performed. Results: There were 34.2% of women and 65.8% of men. CS was diagnosed in 3589 (6.3%) patients (females 7.3% vs. males 5.7%, p<0.003). In multivariate analysis CS was the strongest factor affecting both inhospital (OR 2.51; 95%CI 2.25-2.80; p<0.0001) and 12-month (OR 2.09; 95%CI 1.96-2.24; p<0.0001) mortality. The worst prognosis was associated with pulmonary edema, advanced age, left or right bundle branch block, atrial fibrillation, and anterior MI. An early invasive strategy up to six hours from the symptom onset were the only factors reducing in-hospital and 12-month mortality. Despite of high female ratio in the group with CS and higher mortality in the female group, the female sex did not influence the in-hospital prognosis. Conclusion: In spite of enormous progress in the treatment of STEMI cardiogenic shock remains an important complication affecting the in-hospital and long-term prognosis. A symptom onset-to-treatment time is the key element in the management of patients with CS. Proper diagnosis and management including wide interventional strategy implementation increase the survival chance. An intensive study on novel treatment modalities and on effective identification methods of patients at risk and are warranted.