Venoarterial Membrane Oxygenation in cardiogenic shock complicated from an acute myocardial infarction: an overview and comprehensive meta-analysis

Background Cardiogenic shock (CS) remains a significant cause of mortality in patients with acute coronary syndrome (ACS), despite early interventions, such as coronary revascularization. Mechanical circulatory support devices, particularly venoarterial extracorporeal membrane oxygenation (VA-ECMO), are increasingly being utilized to address this issue. Limited randomized controlled trials exist to evaluate the efficacy of VA-ECMO in CS related to ACS. Purpose In order to assess this gap in literature, we performed this meta-analysis of trials investigating VA-ECMO in this clinical setting of ACS related CS. Methods A meta-analysis was conducted to assess the effectiveness of VA-ECMO in adult patients with infarct-related CS. Trials were identified through database searches and selected based on specific inclusion criteria. The primary outcome was 30-day all-cause mortality, with secondary outcomes including bleeding and vascular complications. Major bleeding, considered as bleeding BARC (Bleeding Academic Research Consortium) > 2, TIMI (Thrombolysis in Myocardial Infarction) Major or GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen activator for Occluded coronary arteries) severe bleeding and critical limb ischemia were secondary outcomes. Statistical pooling for incidence estimates was performed according to a random-effect model with generic inverse-variance weighting, computing risk estimates with 95% confidence intervals (CIs). Small study bias was appraised by graphical inspection of funnel plots. Meta-regression analysis and leave-one-out analysis were performed to assess the impact of baseline features on the primary end point with Comprehensive Meta-analysis software. Results A total of 24 studies met the inclusion criteria and were included in the meta-analysis, involving 4706 patients (Figure 1). The median age of the patients was 61.8 ± 4.1 years, 76% of them being males. Admission lactate levels ranged from 5.6 to 14 mmol/l, suggesting a state of profound shock. The analysis revealed that 30-day mortality rates for patients with cardiogenic shock receiving VA-ECMO were still high with a mortality of 63%. Vascular complications were identified as factors associated with a worse prognosis. The overall ischemia rate averaged 12.9 ± 5.1%, with a range from 7.1% to 22%. Regarding bleeding complications, an overall incidence of 21 ± 6.9%, varying from 3.2% to 33%, was demonstrated (Figure 2). Conclusions The meta-analysis highlights the ongoing challenge of high mortality rates in CS patients despite the use of VA-ECMO. While VA-ECMO shows promise in providing circulatory support, further research is needed to explore ways to improve outcomes and reduce complications associated with the use of these devices. The complexity of patient management in CS cases underscores the need for a multidisciplinary approach to optimize treatment strategies and enhance patient outcomes.Figure 1Figure 2