Optimal patient and mechanical circulatory support device selection in acute myocardial infarction cardiogenic shock

• Published in: The Lancet (British edition) 2024-09, Vol.404 (10457), p.992-993
• Main Authors: Jentzer, Jacob C, Hibbert, Benjamin
• Format: Article
• Language: English
• Subjects: Aorta; Balloon treatment; Blood pressure; Brain injury; Cardiac arrest; Cerebral infarction; Clinical trials; Coma; Devices; Extracorporeal membrane oxygenation; Fatalities; Head injuries; Heart attacks; Injury analysis; Mechanical unloading; Meta-analysis; Mortality; Myocardial infarction; Oxygenation; Patients; Pressure effects; Reperfusion; Shock; Subgroups; Survival; Thrombolysis; Traumatic brain injury; Ventricular assist devices
• ISSN: 0140-6736; 1474-547X; 1474-547X
• DOI: 10.1016/S0140-6736(24)01588-5

Temporary mechanical circulatory support (TMCS) has been used in patients with acute myocardial infarction and cardiogenic shock (AMICS) since the introduction of passive intra-aortic balloon counterpulsation more than 50 years ago.1,2 Despite the development and expanding use of more sophisticated active TMCS devices, such as percutaneous ventricular assist devices (PVADs) and venoarterial extracorporeal membrane oxygenation devices (VA-ECMO), outcomes of patients with AMICS remain unacceptably poor.1–6 Although proponents have argued that tailored use of the correct device in the correct patient can save lives, randomised clinical trials of TMCS have uniformly failed to show improved survival in broad cohorts with cardiogenic shock.2,3,7–9 The recent Danger-Shock trial reported that early use of PVAD in certain patients with cardiogenic shock due to ST-elevation acute myocardial infarction (STEMI) without anoxic brain injury improved survival despite more non-fatal complications.10 The finding of better survival with TMCS in selected patients with AMICS in Danger-Shock has led to uncertainty about whether TMCS can be beneficial in other subgroups of patients with AMICS, and whether the potential benefit varies between different TMCS devices. In The Lancet, Holger Thiele and colleagues11 addressed these questions in a meta-analysis using individual patient data from 1059 patients (median age 65 years [IQR 57–73], 845 [79·9%] of 1058 patients with data were male and 213 [20·1% were female) from nine randomised controlled trials of TMCS in AMICS to explore the effects of loading versus unloading TMCS devices on 6-month mortality, including important patient subgroups; as expected, the findings mostly recapitulate the findings of the largest included studies.9,10 When all patients with AMICS and who received TMCS devices were analysed together, no improvement in survival was observed at 6 months with TCMS (50·7% [95% CI 46·5–55·0; 268 deaths observed] vs 55·9% in the control group 51·7–60·2; 293 deaths; hazard ratio [HR] 0·87, 95% CI 0·74–1·03; p=0·10).11 The effect was similar when examining both unloading (PVAD) and loading (VA-ECMO) devices, although the confidence interval for the effect of PVAD on mortality suggested a probable benefit (47·3% [95% CI 41·3–53·7] 6-month mortality [117 deaths] vs 56·9% [50·8–63·3] 6-month mortality [137 deaths] in the control group; HR 0·80, 95% CI 0·62–1·02; p=0·075). The important subgroup of patients with STEMI-related