Utility of venoarterial extracorporeal membrane oxygenation in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Background Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) continues to portend poor clinical prognosis and remains a major cause of morbidity and mortality. Although venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is frequently used in the treatment of AMI-CS, studies evaluating its benefit compared to percutaneous ventricular assist devices (pVAD) or standard medical therapy in this patient population have yielded conflicting results. Purpose The goal of this meta-analysis is to evaluate the use of ECMO compared to either pVAD or medical therapy with or without intra-aortic balloon counterpulsation (IABP) in patients presenting with AMI-CS. Methods A database search was performed for studies reporting on the association of ECMO compared to pVAD or medical therapy with or without IABP with clinical outcomes in patients with AMI-CS. The endpoints of interest were 30-day all-cause mortality and long term all-cause mortality. The databases searched included Pubmed, Web of Science, and Embase. The search was not restricted by time or publication status. Registry studies were excluded from this analysis. Results A total of 8 studies with 937 participants (447 treated with ECMO, 243 treated with pVAD, 247 treated with medical therapy with or without IABP) met inclusion criteria. Mean age was 63 years old, 80.5% were men, mean left ventricular ejection fraction was 26%, mean follow-up was 6.3 months (ranging 1-12 months). Treatment of AMI-CS patients with ECMO was not associated with lower risk of 30-day all-cause mortality compared to pVAD or standard medical therapy with or without IABP placement (OR 1.29, 95% CI 0.87-1.90; p=0.21; OR 0.58, 95% CI 0.25-1.35; p=0.13). Heterogenetic was low to moderate for each subgroup. Test for subgroup differences did not demonstrate statistically significant differences in the results for pVAD and for standard medical therapy with or without IABP (p=0.10, I2=64.1%). Compared to pVAD, ECMO was not associated lower risk of long-term mortality (OR 1.27, 95% CI 0.85-1.90; p=0.24). The heterogeneity for this analysis was low (I2=0%). Conclusion In patients presenting with AMI-CS, use of VA-ECMO is not associated with lower risk of mortality compared to pVAD or standard medical therapy with or without IABP placement. The risks and benefits of ECMO should be carefully considered compared to other forms of temporary mechanical circulatory support.Figure 1