Percutaneous mechanical circulatory support versus intraaortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract

Abstract Background Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a disease process associated with significantly poor clinical prognosis, placing patients at increased risk for morbidity and mortality. Currently, the optimal choice for temporary mechanical circulatory support remains unclear, with studies evaluating use of percutaneous ventricular assist devices (pVAD) yielding conflicting results. Purpose The goal of this meta-analysis is to evaluate the efficacy of pVAD compared to intra-aortic balloon counterpulsation (IABP) in patients presenting with AMI-CS. Methods A database search was performed for studies reporting on the association of pVAD compared to IABP with clinical outcomes in patients with AMI-CS. The primary endpoint of interest was 30-day all-cause mortality. Secondary endpoints included cardiovascular (CV) mortality, and recurrence of AMI. 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. Subgroup analysis was performed separating randomized controlled trials from retrospective cohort studies. Results A total of 8 studies with 651 participants (322 treated with pVAD, 329 treated with IABP) met inclusion criteria. Mean age was 65 years old, 73.9% were men, mean left ventricular ejection fraction was 28%, mean follow-up was 9.8 months (ranging 1-66 months). Treatment of AMI-CS patients with pVAD was not associated with lower risk of 30-day all-cause mortality compared to IABP (OR 0.90, 95% CI 0.63-1.27; p=0.55). Heterogeneity was low for the RCT subgroup and moderate for the cohort study subgroup (I2=0%; I2=48%). Use of pVAD in patients with AMI-CS was associated with a non-statistically significant trend toward lower CV mortality compared to IABP (OR 0.53, 95% CI 0.29-0.99; p=0.05). The heterogeneity was low (I2=0%). Use of pVAD was not associated with significantly lower risk of recurrent AMI (OR 0.62, 95% CI 0.22-1.74; p=0.37). Heterogeneity was low for this analysis (I2=0%). Test for subgroup differences was not statistically significant for any of the above analyses. Conclusion In patients presenting with AMI-CS, use of pVAD compared to IABP is not associated with lower risk of all-cause mortality or recurrent AMI. However given the apparent trend toward lower risk of CV mortality in patients treated with pVAD, additional high-quality prospective studies are required.Figure 1