Incidences and mortality of cardiogenic shock in patients with acute myocardial infarction (AMI) remain high despite substantial therapy improvements in acute percutaneous coronary intervention over the last decades. Extracorporeal membrane oxygenation (ECMO) has become an alternative treatment option in specialized cardiac arrest centers even though there is no randomized controlled data available up to date. Several concepts of unloading the left ventricle are discussed and were analyzed in non-randomized studies and registries. As intra-aortic balloon pump (IABP) therapy has failed to improve mortality in cardiogenic shock as single therapy, its positive impact on coronary circulation may be beneficial in AMI patients with cardiogenic shock on ECMO therapy.
Objective:
The objective of this meta-analysis was to assess the effect of ECMO vs. ECMO + IABP treatment on the mortality of patients with cardiogenic shock due to acute myocardial infarction. Methods: A systematic literature search was performed using the EMBASE and MEDLINE database. Studies comparing the effect of ECMO vs. ECMO + IABP on the mortality of patients with AMI were included. Meta-analyses were performed to analyze the effect of the chosen treatment on mortality. We excluded studies in which the cause of the cardiogenic shock was unclear and/or survival rates were not given separately for the ECMO and the ECMO + IABP therapy groups.
Results:
Twelve retrospective studies were identified by the literature search, none of such was a randomized controlled trial. Overall, a total of 2317 patients, of which 73% were male were included. 1241 patients received ECMO treatment only, and 1076 patients received a treatment including an ECMO combined with an IABP. Nine studies reported mortality as in-hospital mortality, two as 30-day mortality and one as 28-day mortality. The performed meta-analysis showed a decreased mortality after ECMO + IABP compared to ECMO only treatment for patients with cardiogenic shock due to myocardial infarction (OR 0.52, 95% CI [0.44 – 0.63], p < 0.001; Figure 1). To perform a sensitivity analysis, we removed the largest trail by Aso et. al, and the effect sustained favoring ECMO + IABP therapy (OR 0.53, 95% CI [0.37 – 0.76], p < 0.001; Figure 2).
Conclusions:
In this meta-analysis combination therapy of ECMO + IABP was superior to ECMO only therapy in patients with cardiogenic shock due to acute myocardial infarction. In the absence of randomized data these results should be interpreted with caution.
Figure 1:
Figure 2:
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