Log in to MyACC
Temporary Mechanical Circulatory Support in Infarct-Related CS
Quick Takes
- Early routine use of mechanical circulatory support (MCS) in patients with infarct-related cardiogenic shock (in addition to revascularization) does not improve 6-month all-cause mortality.
- Patients with STEMI without risk of hypoxic brain injury had reduced mortality with MCS. All active MCS devices were associated with increase in bleeding and vascular complications.
- MCS use should only be reserved for selected patients i.e., patients with STEMI and cardiogenic shock without risk of hypoxic brain injury.
Study Questions:
What is the effect of early routine active percutaneous mechanical circulatory support (MCS) versus control treatment on 6-month all-cause mortality in patients with acute myocardial infarction-related cardiogenic shock (AMICS)?
Methods:
The investigators conducted an individual patient data meta-analysis of randomized controlled trials without language restriction, by querying the electronic databases MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, and Embase, as well as ClinicalTrials.gov, up to January 26, 2024. All randomized trials with 6-month mortality data comparing early routine active MCS (directly in the catheterization laboratory after randomization) versus control in patients with AMICS were included. The primary outcome was 6-month all-cause mortality in patients with AMICS treated with early routine active percutaneous MCS versus control, with a focus on device type (loading, such as venoarterial extracorporeal membrane oxygenation [VA-ECMO] vs. unloading) and patient selection. Hazard ratios (HRs) of the primary outcome measure were calculated using Cox regression models. This study is registered with PROSPERO, CRD42024504295.
Results:
Nine reports of randomized controlled trials (n = 1,114 patients) were evaluated in detail. Overall, four randomized controlled trials (n = 611 patients) compared VA-ECMO with a control treatment and five randomized controlled trials (n = 503 patients) compared left ventricular (LV) unloading devices with a control treatment. Two randomized controlled trials also included patients who did not have AMICS, who were excluded (55 patients [44 who were treated with VA-ECMO and 11 who were treated with an LV unloading device]). The median patient age was 65 years (interquartile range, 57-73); 845 (79.9%) of 1,058 patients with data were male and 213 (20.1%) were female. No significant benefit of early unselected MCS use on 6-month mortality was noted (HR, 0.87 [95% CI, 0.74-1.03]; p = 0.10). No significant differences were observed for LV unloading devices versus control (0.80 [0.62-1.02]; p = 0.075), and loading devices also had no effect on mortality (0.93 [0.75-1.17]; p = 0.55). Patients with ST-elevation cardiogenic shock (CS) without risk of hypoxic brain injury had a reduction in mortality with MCS use (0.77 [0.61-0.97]; p = 0.024). Major bleeding (odds ratio, 2.64 [95% CI, 1.91-3.65]) and vascular complications (4.43 [2.37-8.26]) were more frequent with MCS use than with control.
Conclusions:
The authors report that the use of active MCS devices in patients with AMICS did not reduce 6-month mortality (regardless of the device used) and increased major bleeding and vascular complications.
Perspective:
This collaborative individual patient data meta-analysis reports that early routine use of MCS in patients with infarct-related CS (in addition to revascularization) does not improve 6-month all-cause mortality. Furthermore, this finding was independent of the use of LV unloading or loading devices. However, of note, patients with ST-segment elevation myocardial infarction (STEMI) without risk of hypoxic brain injury had reduced mortality with MCS. In addition, all active MCS devices were associated with increase in bleeding and vascular complications. Based on these and other available data, MCS use should only be reserved for selected patients, i.e., patients with STEMI and CS without risk of hypoxic brain injury.
Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure, Acute Coronary Syndromes
Keywords: Mechanical Circulatory Support, Myocardial Infarction, Shock, Cardiogenic
< Back to Listings
