Extracorporeal membrane oxygenation in cardiogenic shock: evidence, limitations, and patient selection in the contemporary era

Cardiogenic shock (CS) is a life-threatening condition with severely impaired myocardial contractility, causing systemic hypoperfusion, tissue hypoxia, and organ dysfunction. Despite the advances in revascularisation and pharmacological therapies, CS carries high mortality among patients with acute myocardial infarctions and other acute cardiac syndromes. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) offers short-term mechanical circulatory support in refractory CS by restoring systemic perfusion and maintaining end-organ oxygenation. This narrative review aims to explain the physiological basis of V-A ECMO, summarize the findings from randomized clinical trials (RCTs) and observational studies, and evaluate the clinical factors that affect mortality outcomes in CS. Recent RCTs assessing routine early V-A ECMO initiation in acute myocardial infarction - related CS include ECLS-SHOCK, ECMO-CS, and EURO-SHOCK. The results did not show a clear early mortality benefit with routine ECMO initiation and reported higher rates of bleeding and vascular complications. Appropriate patient selection based on shock phenotype, optimal timing of support, clinical assessment, and management of V-A ECMO-associated complications are critical determinants of clinical effectiveness. It is still a valuable rescue option for refractory CS when appropriately selected based on reversibility potential and institutional capabilities, rather than as routine first-line therapy for all patients with acute MI-related shock.