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VA-ECMO in Patients With Infarct-Related Cardiogenic Shock
Quick Takes
- This large individual patient-level data meta-analysis does not show any survival benefit with the early routine use of VA-ECMO in patients with infarct-related cardiogenic shock.
- Furthermore, there is no subgroup in which VA-ECMO was superior to optimal medical therapy.
- Overall, these data do not justify unselected use of VA-ECMO in patients with infarct-related cardiogenic shock.
Study Questions:
What is the effect of venoarterial extracorporeal membrane oxygenation (VA-ECMO) on 30-day death rate in patients with cardiogenic shock?
Methods:
The investigators identified randomized clinical trials comparing early routine use of VA-ECMO versus optimal medical therapy alone in patients presenting with infarct-related cardiogenic shock by searching MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and trial registries until June 12, 2023. Trials were included if at least all-cause death rate 30 days after in-hospital randomization was reported and trial investigators agreed to collaborate (i.e., providing individual patient data). Odds ratios (ORs) as primary outcome measure were pooled using logistic regression models. This study is registered with PROSPERO (CRD42023431258).
Results:
Four trials (n = 567 patients; 284 VA-ECMO, 283 control) were identified and included. Overall, there was no significant reduction of 30-day death rate with the early use of VA-ECMO (OR, 0.93; 95% confidence interval [CI], 0.66–1.29). Complication rates were higher with VA-ECMO for major bleeding (OR, 2.44; 95% CI, 1.55–3.84) and peripheral ischemic vascular complications (OR, 3.53; 95% CI, 1.70–7.34). Prespecified subgroup analyses were consistent and did not show any benefit for VA-ECMO (p for interaction ≥ 0.079).
Conclusions:
The authors report that VA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed.
Perspective:
This large individual patient-level data meta-analysis of four prospective randomized clinical trials does not show any survival benefit with the early routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Furthermore, there is no subgroup in which VA-ECMO was superior to optimal medical therapy. On the contrary, a consistent increase in bleeding and vascular complications with the use of VA-ECMO was observed. Additional studies are indicated to assess other disease-modifying therapies or to identify patients who might benefit from mechanical circulatory support, to further improve outcome in patients with cardiogenic shock. Overall, these data do not justify unselected use of VA-ECMO in patients with cardiogenic shock.
Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure
Keywords: Acute Coronary Syndrome, ESC Congress, ESC23, Heart Failure, Hemorrhage, Ischemia, Peripheral Vascular Diseases, Secondary Prevention, Shock, Cardiogenic
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