Venoarterial extracorporeal membrane oxygenation combined with hemoperfusion for acute myocardial infarction complicated by cardiogenic shock: the pilot study, a single-center randomized controlled trial

Background and purpose: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with a poor prognosis. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary circulatory support, it does not directly remove circulating inflammatory mediators and may further amplify systemic inflammation. This study investigated whether combining VA-ECMO with hemoperfusion (HP) could modulate inflammatory responses and improve organ function in patients with AMI-CS. Methods: This single-center, prospective, exploratory pilot randomized controlled trial enrolled 32 patients with AMI-CS who received VA-ECMO support between October 2021 and September 2024. Patients were randomly assigned in a 1:1 ratio to receive VA-ECMO alone (n = 17) or VA-ECMO combined with HP (n = 15). Biomarkers of inflammation, oxidative stress, and vascular activity were measured before VA-ECMO initiation and at 12, 24, 48, and 72 hours thereafter. Longitudinal changes were analyzed using linear or generalized linear mixed-effects models, as appropriate. Results: Baseline characteristics were generally comparable between the two groups, except for sex distribution (P = 0.036). Significant group-by-time interactions were observed for 12 of the 13 measured biomarkers (all P < 0.05), whereas the interaction for endothelin-1 was not significant (P = 0.075), indicating different temporal biomarker profiles between the two groups. In particular, nitric oxide (P = 0.041) and superoxide dismutase (P = 0.045) showed significantly more favorable changes in the combined-treatment group. At the time of VA-ECMO weaning, the combined-treatment group had a lower Sequential Organ Failure Assessment score (7 [6.0–9.0] vs. 9 [7.5–9.5]; P = 0.045) and a lower vasoactive-inotropic score (8.4 ± 1.2 vs. 10.3 ± 1.9; P = 0.002) than the VA-ECMO monotherapy group. The rate of successful VA-ECMO weaning was numerically higher in the combined-treatment group, although the difference was not statistically significant (86.7% vs. 58.8%; P = 0.080). No significant between-group differences were observed in in-hospital mortality (26.7% vs. 35.3%; P = 0.599) or 30-day survival (53.3% vs. 41.2%; P = 0.492). Conclusions: In this exploratory pilot trial, the addition of HP to VA-ECMO was associated with favorable changes in inflammatory and oxidative stress biomarkers and with improved organ function and reduced vasoactive support at the time of VA-ECMO weaning in patients with AMI-CS. However, it did not significantly improve short-term survival or reduce adverse events. Larger multicenter randomized trials are needed to confirm these findings.