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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Percutaneous Mechanical Circulatory Support in Post-Myocardial Infarction Cardiogenic Shock: A Systematic Review and
Hamza Ouazani Chahdi1, Léa Berbach1, Laurie-Anne Boivin-Proulx2
1Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.
Insights
Percutaneous mechanical support (pMCS) devices for cardiogenic shock after acute myocardial infarction (AMI) show mixed results. Intra-aortic balloon pump (IABP) may reduce mortality in specific cases, but overall evidence quality is low.
Area of Science:
- Cardiology
- Interventional Cardiology
- Critical Care Medicine
Background:
- Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI), leading to high early mortality.
- The role of percutaneous mechanical support (pMCS) devices in improving outcomes for AMI-complicated CS remains uncertain.
Purpose of the Study:
- To systematically review and analyze the existing evidence on the effectiveness of pMCS devices in reducing mortality in patients with AMI-complicated CS.
Main Methods:
- A systematic review and meta-analysis were conducted using data from Medline, Embase, Google Scholar, and the Cochrane Library.
- Fifty relevant studies were included in the quantitative analysis, with additional references sourced elsewhere.
Main Results:
- Intra-aortic balloon pump (IABP) showed a significant mortality reduction in specific subgroups (failed primary percutaneous coronary intervention or thrombolysis).
- Impella did not demonstrate an advantage over conventional therapy and showed increased mortality compared to IABP.
- Extracorporeal membrane oxygenation (ECMO) did not show a mortality advantage, but adding IABP or Impella to ECMO might improve early mortality.
- All pMCS strategies were associated with an increased risk of severe bleeding (Bleeding Academic Research Consortium ≥ 3).
Conclusions:
- The current evidence supporting pMCS in AMI-CS is of poor to moderate quality, with limited randomized data.
- IABP may be beneficial in selected patients with AMI-CS, particularly those treated with thrombolysis or failed primary percutaneous coronary intervention.
- Consideration should be given to adding IABP or Impella for patients requiring ECMO support for CS.
- Increased bleeding risk is a significant concern with all pMCS strategies.
Background:
Cardiogenic shock (CS) complicates 5%-10% of acute myocardial infarction (AMI) and is the leading cause of early mortality. It remains unclear whether percutaneous mechanical support (pMCS) devices improve post-AMI CS outcome.
Methods:
A systematic review of original studies comparing the effect of pMCS on AMI-CS mortality was conducted with the use of Medline, Embase, Google Scholar, and the Cochrane Library databases.
Results:
Of 8672 records, 50 were retained for quantitative analysis. Four additional references were added from other sources. Four references reported a significant mortality reduction with intra-aortic balloon pump (IABP) in patients with failed primary percutaneous coronary intervention (pPCI) or managed with thrombolysis. Meta-analyses showed no advantage of Impella over conventional therapy (pooled OR 0.55, 95% CI 0.20-1.46; I2 = 0.85) and increased mortality compared with IABP (pooled OR 1.32; 95% CI 1.08-1.62; I2 = 0.85). No study reported a mortality advantage for extracorporeal membrane oxygenation (ECMO) over conventional therapy, IABP, or Impella support. Early mortality might be improved with the addition of IABP or Impella to ECMO. Bleeding Academic Research Consortium ≥ 3 bleeding was increased with every pMCS strategy.
Conclusions:
The current evidence is of poor to moderate quality, with only 1 in 5 included articles reporting randomised data and several reporting unadjusted outcomes. Yet, there is some evidence to favour IABP use in the setting of thrombolysis or with failed pPCI, and adding IABP or Impella should be considered for patients requiring ECMO.
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