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

Background Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains a condition associated with high morbidity and mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in treatment of AMI-CS, however the safety of this therapy compared to alternative forms of mechanical circulatory support (MCS) such as percutaneous ventricular assist devices (pVAD) remains unclear. Aim The goal of this meta-analysis is to evaluate the association of ECMO compared to pVAD with safety outcomes patients presenting with AMI-CS. Methods A database search was performed for studies reporting on the association of ECMO compared to pVAD with safety outcomes in patients with AMI-CS. The endpoints of interest were device-related limb complications, ischemic cerebrovascular accident (CVA), and occurrence of moderate to severe bleeding. 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 6 studies with 868 participants (410 treated with ECMO, 458 treated with pVAD) met inclusion criteria. Mean age was 62 years old, 80.3% were men, mean left ventricular ejection fraction was 26%, mean follow-up was 5.2 months (ranging 1-12 months). Treatment with ECMO in patients with AMI-CS was associated with significantly higher risk of device-related limb ischemia and moderate to severe bleeding compared to pVAD (OR 2.84, 95% CI 1.56-5.17; p<0.01; OR 2.18, 95% CI 1.17-4.06; p=0.01). Heterogeneity for these analyses was low (I2=0%). Treatment with ECMO in patients with AMI-CS was not associated with higher risk of ischemic CVA compared to pVAD (OR 1.60, 95% CI 0.47-5.43; p=0.45). Heterogeneity for this analysis was low (I2=0%). Conclusion In patients presenting with AMI-CS, use of VA-ECMO is associated with significantly higher risk of device-related limb ischemia and bleeding compared to use of pVAD but is not associated with higher risk of ischemic CVA. Given these significant risks, additional high-quality studies are needed to further elucidate the clinical benefits of ECMO use in this patient population.