Mechanical circulatory support in patients with cardiogenic shock not secondary to cardiotomy: a network meta-analysis

Abstract

To compare the efficacy and safety of different mechanical circulatory support (MCS) devices in CS. A total of 24 studies (7 randomized controlled trials—RCTs—and 17 non-RCTs) involving 11,117 patients were entered in a Bayesian network meta-analysis. The primary endpoint was 30-day mortality. Secondary endpoints were stroke and bleeding (requiring transfusion and/or intracranial and/or fatal). Compared with no MCS, extra-corporeal membrane oxygenation (ECMO) reduced 30-day mortality when used both alone (OR 0.37, 95% CrI 0.15–0.90) and together with the micro-axial pump Impella (OR 0.13, 95% CrI 0.02–0.80) or intra-aortic balloon pump (IABP) (OR 0.19, 95% CrI 0.05–0.63), although the relevant articles were affected by significant publication bias. Consistent results were obtained in a sensitivity analysis including only studies of CS due to myocardial infarction. After halving the weight of studies with a non-RCT design, only the benefit of ECMO + IABP on 30-day mortality was maintained (OR 0.22, 95% CI 0.057–0.76). The risk of bleeding was increased by TandemHeart (OR 13, 95% CrI 3.50–59), Impella (OR 5, 95% CrI 1.60–18), and IABP (OR 2.2, 95% CrI 1.10–4.4). No significant differences were found across MCS strategies regarding stroke. Although limited by important quality issues, the studies performed so far indicate that ECMO, especially if combined with Impella or IABP, reduces short-term mortality in CS. MCS increases the hazard of bleeding.

Mechanical Unloading of the Left Ventricle before Coronary Reperfusion in Preclinical Models of Myocardial Infarction without Cardiogenic Shock: A Meta-Analysis

“…MCSs are nowadays part of the routine practice in case of cardiogenic shock [ 27 ] and high-risk PCI [ 28 ], settings in which they ensure systemic and coronary perfusion by supporting/replacing, to a various extent, the physiological systolic output. In addition, a number of contemporary MCSs are able to relieve LV pressures and volumes reducing myocardial work and, thereby, oxygen consumption [ 29 , 30 ].…”

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery

“…Zhang et al (2022) found, in a meta-analysis reviewing 4416 articles, that IABP is more effective for the treatment of cardiogenic shock, reducing the incidence of 30-day mortality compared with VA-ECMO and Impella [ 17 ]. The study by Alushi et al (2019) states that IABP has been downgraded in guidelines after the IABP-SHOCK II trial failed to prove any mortality benefit over medical therapy alone [ 86 , 87 ]. Common risks when using MCS include bleeding and strokes.…”

“…In both cases, IABP was found to perform better than Impella and TandemHeart, because of the non-mandatory use of unfractionated heparin for IABP. However, compared to other MCS devices, the risk of bleeding is significantly higher [ 87 ]. Nevertheless, the same study shows the SUCRA values of the different MCS devices on a scale from 0 to 1, where IABP achieved the worst score of the 6 that were compared (IABP, Impella, TandemHeart, ECMO, ECMO + IABP, and ECMO + Impella) [ 87 ].…”

“…However, compared to other MCS devices, the risk of bleeding is significantly higher [ 87 ]. Nevertheless, the same study shows the SUCRA values of the different MCS devices on a scale from 0 to 1, where IABP achieved the worst score of the 6 that were compared (IABP, Impella, TandemHeart, ECMO, ECMO + IABP, and ECMO + Impella) [ 87 ]. Guidelines assign a Class IIa recommendation to IABP for stage D congestive heart failure patients [ 51 , 86 ].…”