Mechanical circulatory support for infarct-related cardiogenic shock: a systematic review, pairwise and network meta-analysis.

Aims: Mortality from cardiogenic shock complicating acute myocardial infarction (AMI-CS) remains high, despite the increasing mechanical circulatory support (MCS) use in clinical practice.

Methods and results: We undertook a systematic review and meta-analysis of trials assessing MCS in adults with AMI-CS. We searched Medline, EMBASE, CENTRAL, Web of Science, and Scopus from inception to May 2024. We evaluated the effect of each intervention on early mortality using a random-effects network meta-analysis of odds ratios (ORs). Safety outcomes included stroke, bleeding, and sepsis. Fourteen trials randomizing 1858 patients were included: intra-aortic balloon pump (IABP) vs. medical therapy (four trials, n = 748 patients), veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) vs. No VA-ECMO (four trials, n = 568 patients), percutaneous ventricular assist device (pVAD) vs. No pVAD (six trials, n = 542 patients). No MCS device showed a significant effect on early mortality vs. initial medical therapy {IABP (OR 0.87, 95% CI 0.66-1.15), VA-ECMO (OR 0.91, 95% CI 0.65-1.27), pVAD (OR 0.80, 95% CI 0.56-1.14), and P (inconsistency) = 0.76}. VA-ECMO and pVAD were associated with increased major bleeding [OR 2.81 (95% CI 1.68-4.71) and OR 5.13 (95% CI 1.87-14.04), respectively]. Higher rates of stroke and sepsis were noted with pVAD. No significant safety concerns were identified with IABP.

Conclusion: The mortality benefit of MCS devices in AMI-CS remains uncertain. Using such devices may be associated with increased risks, including major bleeding, stroke, and sepsis. Current evidence does not support the routine use of MCS devices in the management of AMI-CS.