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cardio.cardiogenic-shock.post-stem-cell-transplant.v1

Cardiogenic shock — post-hematopoietic-stem-cell-transplant recipient

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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to cardiogenic shock arising in the post-hematopoietic-stem-cell-transplant (HSCT) recipient. Etiology spectrum: conditioning-regimen cardiotoxicity (cyclophosphamide hemorrhagic myocarditis per Goldberg JCO 1986 PMID 3528404; busulfan endocardial fibrosis; TBI premature CAD); GVHD-related cardiac (rare); opportunistic infections (CMV myocarditis peak 30–100 d post-allo, EBV, adenovirus, HHV-6); sepsis-induced CS in profoundly immunosuppressed neutropenic recipients per Tichelli EBMT 2008 PMID 18176622 + Yeh & Bickford JACC 2009 PMID 19608050. Workup pivots: STAT echo for biventricular function + pericardial effusion (cyclophosphamide hemorrhagic pericarditis); CMR with Lake Louise 2018 + T2*/SWI for hemorrhagic signal (Ferreira JACC 2018 PMID 30025572); EMB per AHA/ACC/ESC 2007 (Cooper PMID 17998456) when diagnosis-changing; CMV PCR + viral panel; sepsis workup (blood cultures, fungal, β-D-glucan, galactomannan); calcineurin inhibitor trough; engraftment status. Treatment ACUTE: standard CS support (NE first-line per SOAP-II PMID 20200382); cyclophosphamide hemorrhagic myocarditis → high-dose methylprednisolone 1 g IV daily × 3–5 d + supportive (Goldberg 1986); CMV myocarditis → ganciclovir + IVIG per ASTCT (PMID 20530287); sepsis → SSC 2026 bundle + broad-spectrum + antifungal + G-CSF if neutropenic; GVHD cardiac → optimize systemic GVHD treatment (steroids + ruxolitinib for steroid-refractory per REACH-2 NEJM 2020); AVOID nephrotoxic drugs given calcineurin inhibitor on board for GVHD prophylaxis (additive AKI risk). MCS bridge to recovery is REASONABLE in selected cases — but must weigh underlying malignancy prognosis, GVHD severity, transplant + oncology + cardio-oncology MDT input mandatory. Mortality is HIGH (>60% in published series) given immunosuppression + multi-organ + underlying malignancy. Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for HSCT-recipient context — CMV / cyclophosphamide / sepsis / GVHD diagnostic axis, sub-etiology-specific treatment, nephrotoxin avoidance on calcineurin inhibitor, MDT-gated MCS decisions, cancer-prognosis-weighted ICD eligibility. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 13 cancer-related variant.

Entry points (5)

  • history
    Recent high-dose cyclophosphamide conditioning (≥120 mg/kg) within past 1–10 d + acute HF + ↑ troponin → cyclophosphamide hemorrhagic myocarditis (Goldberg JCO 1986 PMID 3528404)
    recent_high_dose_cyclophosphamide_conditioning_with_acute_hf
  • history
    HSCT recipient (allogeneic or autologous) within past 100 d + acute biventricular dysfunction + shock physiology — multi-etiology CS workup
    post_hsct_recipient_with_acute_hf_and_shock
  • lab_abnormality
    CMV PCR positive + acute LV dysfunction in post-HSCT recipient (peak 30-100 d) → CMV myocarditis differential
    cmv_pcr_positive_with_acute_hf_post_hsct
  • symptom
    Sepsis physiology in neutropenic post-HSCT recipient with cardiac dysfunction → mixed septic + cardiogenic shock
    sepsis_in_neutropenic_post_hsct_with_shock
  • imaging
    Cardiac MRI: T2 edema + LGE + T2*/SWI hemorrhagic signal + biventricular dysfunction post-cyclophosphamide → hemorrhagic myocarditis
    cmr_lake_louise_with_hemorrhagic_pattern_post_cyclophosphamide

Required inputs (17)

  • agerequired
    demographic • used at CONTEXT
    Older HSCT recipients higher cardiotoxicity risk; age informs prognosis and recovery candidacy
  • transplant_type_and_dayrequired
    history • used at CONTEXT
    Allogeneic vs autologous; day-post-transplant determines etiology spectrum (early = conditioning toxicity; 30-100 d = CMV / GVHD)
  • conditioning_regimenrequired
    history • used at CONTEXT
    Cyclophosphamide ≥120 mg/kg cumulative; busulfan; TBI dose — drives cardiotoxicity differential
  • gvhd_prophylaxis_regimenrequired
    medication • used at CONTEXT
    Calcineurin inhibitor (cyclosporine / tacrolimus) on board → AKI risk + drug-interaction risk; informs avoid-list
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline; gates vasopressor escalation
  • hrrequired
    vital • used at CONTEXT
    Tachycardia common in sepsis-induced or volume-loss states; bradyarrhythmia in advanced cardiac toxicity
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Markedly elevated typical for cyclophosphamide hemorrhagic myocarditis or CMV myocarditis; trend correlates with severity
  • bnp_ntprobnprequired
    lab • used at INITIAL_WORKUP
    Acute HF marker; trend tracks recovery
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    SCAI 2022 staging + CardShock prognostication (Harjola EHJ 2015 PMID 26333869)
  • creatininerequired
    lab • used at CONTEXT
    Baseline AKI; calcineurin inhibitor nephrotoxicity contributes; gadolinium contrast safety for CMR
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Engraftment status; absolute neutrophil count gates infection-risk stratification + G-CSF decision
  • cmv_pcrrequired
    lab • used at BRANCHING_WORKUP
    Quantitative CMV viral load — peak 30-100 d post-allogeneic HSCT; PCR positive + cardiac dysfunction → CMV myocarditis differential
  • blood_culturesrequired
    lab • used at INITIAL_WORKUP
    Sepsis-precipitated CS in immunosuppressed recipient; bacterial / fungal coverage decision
  • echorequired
    imaging • used at INITIAL_WORKUP
    Biventricular function; pericardial effusion (cyclophosphamide hemorrhagic pericarditis); regional vs global pattern
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Diffuse ST/T-wave changes; PR depression in pericarditis overlap; new conduction abnormality possible in myocarditis
  • cmr
    imaging • used at BRANCHING_WORKUP
    Lake Louise Criteria 2018 (Ferreira PMID 30025572); T2*/SWI hemorrhagic signal in cyclophosphamide myocarditis; deferred until stable for transport + adequate eGFR for gadolinium
  • endomyocardial_biopsy
    imaging • used at BRANCHING_WORKUP
    Reserved for diagnosis-changing scenarios — viral PCR negative + atypical pattern; per AHA/ACC/ESC 2007 EMB consensus (Cooper PMID 17998456)

12-phase flow (11)

  1. 1FRAME
    Confirm post-HSCT context; establish day-post-transplant + conditioning regimen + GVHD prophylaxis; identify suspected sub-etiology (cyclophosphamide hemorrhagic myocarditis vs CMV myocarditis vs sepsis-induced vs GVHD cardiac vs busulfan / TBI late effect)
    inputs: transplant_type_and_day, conditioning_regimen
    advance: Post-HSCT context established + sub-etiology hypothesis stated
  2. 2ENTRY
    CS team activation; STAT echo for biventricular function + pericardial effusion; mobilize transplant + oncology + cardio-onc MDT early; sepsis workup mandatory in immunosuppressed recipient
    inputs: sbp, lactate
    advance: CS team + transplant team activated + sepsis workup sent
  3. 3CONTEXT
    Day-post-transplant, conditioning regimen (cyclophosphamide dose, busulfan, TBI), GVHD prophylaxis (cyclosporine / tacrolimus / sirolimus), GVHD status, recent infections, engraftment status, current immunosuppression doses + drug levels
    inputs: hr, creatinine, gvhd_prophylaxis_regimen
    advance: Context complete + sub-etiology working hypothesis stated
  4. 4RED_FLAGS
    Refractory shock (escalate to MCS but weigh underlying prognosis); sepsis-induced CS in profoundly neutropenic patient (high mortality); cardiac tamponade if large cyclophosphamide hemorrhagic pericardial effusion; ventricular arrhythmia in inflamed myocardium
    inputs: sbp, hr
    actions: cardiogenic_shock, cardiac_tamponade
    advance: Arrhythmia + tamponade + sepsis screened, MCS pathway evaluated with MDT
  5. 5INITIAL_WORKUP
    ECG, echo (biventricular dysfunction, pericardial effusion), troponin, BNP, BMP, lactate, CBC w/ diff (ANC), CXR, blood cultures × 2, urine culture; SCAI 2022 staging; sepsis workup ALWAYS
    inputs: ecg, echo, troponin, bnp_ntprobnp, lactate, cbc_with_diff, blood_cultures
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.cbc
    advance: Workup complete + SCAI stage assigned + cultures sent
  6. 6BRANCHING_WORKUP
    CMV PCR + EBV PCR + adenovirus PCR + HHV-6 PCR; β-D-glucan + galactomannan + fungal blood culture; cardiac MRI when stable for transport (T2*/SWI hemorrhagic signal in cyclophosphamide myocarditis); EMB in diagnosis-changing scenarios; current calcineurin inhibitor levels
    inputs: cmv_pcr
    advance: Sub-etiology confirmed by PCR / CMR ± EMB
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; CardShock prognostication; multi-organ failure assessment via SOFA; underlying malignancy prognosis + GVHD status influence MCS / transplant decision; mortality HIGH (>60%) in immunosuppressed recipient with multi-organ involvement per Yeh JACC 2009
    inputs: sbp, lactate, troponin
    advance: Risk stratified + recovery candidacy assessed with MDT
  8. 8TREATMENT
    Standard CS support (NE first-line per SOAP-II); cyclophosphamide hemorrhagic myocarditis → methylprednisolone 1 g IV daily × 3-5 d + supportive (Goldberg 1986); CMV myocarditis → ganciclovir + IVIG (ASTCT); sepsis → SSC 2026 bundle + broad-spectrum + antifungal + G-CSF if neutropenic; GVHD cardiac → optimize systemic GVHD tx (steroids + ruxolitinib for steroid-refractory per REACH-2); AVOID nephrotoxic drugs (calcineurin inhibitor already on board); MCS bridge to recovery in selected cases with MDT input
    inputs: sbp, lactate
    actions: cardiogenic_shock
    advance: Sub-etiology-appropriate therapy started + nephrotoxin-avoidance documented + MCS plan with MDT
  9. 9DISPOSITION
    CICU at MCS-capable + transplant-capable center; transplant team + oncology + cardio-onc + ID MDT activated; advanced HF / transplant evaluation if refractory and underlying malignancy permits
    advance: Disposition assigned with MDT mobilised (cards, transplant, oncology, cardio-onc, ID, ICU)
  10. 10MONITORING
    A-line, central line, lactate clearance, urine output; continuous telemetry; serial echo q24h for LV recovery; daily troponin + BNP; daily CBC w/ diff; calcineurin inhibitor levels q24-48h; CMV PCR weekly; cultures pending
    inputs: lactate, troponin
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence set + reassessment scheduled
  11. 11FOLLOWUP
    Repeat echo + CMR at 4-8 wks for recovery trajectory; cardiac rehab; long-term GDMT 4-pillar if persistent HFrEF; long-term cardio-oncology surveillance for late TBI / busulfan effects; coordination with transplant team for chronic GVHD + immunosuppression management; ICD eligibility per AHA 2017 VA/SCD with cancer-prognosis weighting
    advance: Recovery echo + CMR + GDMT + ICD eligibility timeline + cardio-onc surveillance booked