Primary percutaneous coronary intervention (PCI) decreases myocardial damage and reduces the occurrence of mechanical complications and acute heart failure in patients with ST elevation myocardial infarction (STEMI). Nevertheless, left ventricular (LV) dysfunction remains the leading cause of in-hospital mortality in all subsets of patients and particularly for those in whom primary PCI fails to reopen the infarct-related artery. The clinical scenarios of acute LV failure are heart failure and cardiogenic shock, both conditions being associated with extremely poor outcomes. It has been estimated that LV failure accounts for >75% of the cases of shock complicating acute STEMI. As compared to similar situations, the decision-making process in these patients can potentially benefit from the known coronary anatomy and, in many instances, from the immediate implantation of an intraaortic balloon pump at the time of PCI in selected groups of patients. A thorough clinical and instrumental evaluation is mandatory to discriminate patients who will likely recover (either spontaneously or with further conventional procedures) from those who have irreversible myocardial injury and should be screened for LV assist devices and/or emergent heart transplantation.

In this review, we provide a practical diagnostic and therapeutic algorithm that may be helpful for the clinical management of patients with acute LV failure after primary PCI.