Q46 / 110
After PCI for anterior STEMI, a patient has LVEF 15%, normal oxygenation, mild RV dysfunction, lactate 4.8 mmol/L, and MAP 58 despite norepinephrine. Which initial support best matches current evidence?
Correct answer: B — Initial Impella support
After PCI for anterior STEMI with LVEF 15%, normal oxygenation, mild RV dysfunction, lactate 4.8 mmol/L, and MAP 58 despite norepinephrine, initial Impella support best matches current evidence. See DanGer Shock, which demonstrated that use of a microaxial flow pump with standard care in the treatment of patients with STEMI-related cardiogenic shock led to a lower risk of death from any cause at 180 days than standard care alone. This remains an LV-predominant, nonhypoxemic shock phenotype rather than a routine ECMO phenotype.
Board pearl: DanGer Shock showed lower 180-day mortality with a microaxial flow pump plus standard care in selected STEMI-related cardiogenic shock.
After PCI for anterior STEMI with LVEF 15%, normal oxygenation, mild RV dysfunction, lactate 4.8 mmol/L, and MAP 58 despite norepinephrine, initial Impella support best matches current evidence. See DanGer Shock, which demonstrated that use of a microaxial flow pump with standard care in the treatment of patients with STEMI-related cardiogenic shock led to a lower risk of death from any cause at 180 days than standard care alone. This remains an LV-predominant, nonhypoxemic shock phenotype rather than a routine ECMO phenotype.
Board pearl: DanGer Shock showed lower 180-day mortality with a microaxial flow pump plus standard care in selected STEMI-related cardiogenic shock.
Source(s): Moller et al. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. The New England Journal of Medicine. 2024 Apr;390:1382-1393.
Q47 / 110
Which finding most strongly favors VA-ECMO over isolated Impella support?
Correct answer: B — Persistent severe hypoxemia despite ventilation
VA-ECMO uniquely provides oxygenation plus circulation. A may be managed with isolated LV support. C commonly accompanies LV failure but does not require ECMO. D is not a device-selection criterion.
Board pearl: When oxygenation is part of the failure, include ECMO immediately.
VA-ECMO uniquely provides oxygenation plus circulation. A may be managed with isolated LV support. C commonly accompanies LV failure but does not require ECMO. D is not a device-selection criterion.
Board pearl: When oxygenation is part of the failure, include ECMO immediately.
Q48 / 110
Which echocardiographic finding most strongly indicates the need to initiate active LV unloading during VA-ECMO?
Correct answer: C — Progressive LV dilation with spontaneous echo contrast
Progressive dilation and smoke indicate high filling pressure, stasis, and inadequate decompression. A does not define LV overload. B argues for preserved native ejection. D suggests adequate or excessive unloading.
Board pearl: Echo frequently answers the venting question better than pressure alone.
Progressive dilation and smoke indicate high filling pressure, stasis, and inadequate decompression. A does not define LV overload. B argues for preserved native ejection. D suggests adequate or excessive unloading.
Board pearl: Echo frequently answers the venting question better than pressure alone.
Q49 / 110
Severe RV failure develops during durable LVAD implantation while the chest is open; about one week of RV support is expected. Which strategy best fits the described institutional approach?
Correct answer: B — Surgically implanted Rotaflow or CentriMag RVAD
When severe RV failure develops during durable LVAD implantation while the chest is open and only about one week of support is expected, a surgically implanted Rotaflow or CentriMag RVAD best fits the described institutional approach. Of note, closure of the chest can frequently reduce RV function due to compression against the free wall of the RV, which is one reason open-chest index operations often favor surgical RVAD placement when trouble declares itself early.
Board pearl: Closure of the chest can frequently reduce RV function due to compression against the free wall of the RV.
When severe RV failure develops during durable LVAD implantation while the chest is open and only about one week of support is expected, a surgically implanted Rotaflow or CentriMag RVAD best fits the described institutional approach. Of note, closure of the chest can frequently reduce RV function due to compression against the free wall of the RV, which is one reason open-chest index operations often favor surgical RVAD placement when trouble declares itself early.
Board pearl: Closure of the chest can frequently reduce RV function due to compression against the free wall of the RV.
Q50 / 110
On peripheral VA-ECMO, pulmonary edema, absent aortic valve opening, LV enlargement, and spontaneous echo contrast develop despite stable circuit flow. Which intervention most directly treats the problem?
Correct answer: C — Add active LV unloading
The findings define severe LV overload and stasis; direct unloading addresses pressure and volume. A and D may further raise afterload. B changes gas exchange but does not decompress the LV.
Board pearl: This pattern reflects inadequate unloading, not inadequate ECMO flow.
The findings define severe LV overload and stasis; direct unloading addresses pressure and volume. A and D may further raise afterload. B changes gas exchange but does not decompress the LV.
Board pearl: This pattern reflects inadequate unloading, not inadequate ECMO flow.