Mechanical Circulatory Support Devices versus Standard Medical Therapy for Treatment of Myocardial Infarction Complicated by Cardiogenic Shock: a Network Meta-Analysis.

Abstract

Aim: Cardiogenic shock (CS) is a common sequitur in acute myocardial infarction (AMI), with significant associated mortality. Mechanical circulatory support (MCS) devices have been used in the management of AMI complicated by CS (AMICS). The relative safety and efficacy of these devices in this context is not yet fully established. Our aim is to provide an up-to-date analysis of outcomes to guide future clinical decisions.

Methods and results: We conducted a frequentist network meta-analysis assessing mortality and complications associated with MCS devices, using exclusively randomised controlled trials (RCTs). The devices studied were; Intra-Aortic Balloon Pump (IABP), Impella®, Extracorporeal Membrane Oxygenation (ECMO), and TandemHeart®.A total of eighteen RCTs were identified, with a combined patient population of 1,907. Impella® reduced 6-12 month mortality versus standard medical therapy (risk ratio (RR) 0.81, p < 0.05), but increased requirement for renal replacement therapy, limb complications and major bleeding (RR 1.6, p = 0.02, RR 4.8, p = 0.02, and RR 2.0, p = 0.004 respectively). No other form of MCS demonstrated a statistically significant mortality benefit when compared to medical therapy; however, ECMO increased vascular complications and major bleeding (RR 3.1, p = 0.003 and RR 2.4, p = 0.0001 respectively), and TandemHeart® increased limb complications (RR 19, p = 0.05).

Conclusion: Impella® support in AMICS was associated with a long-term survival benefit. Impella®, ECMO and TandemHeart® use were associated with increased morbidity.