46 A systematic review and meta-analysis of the efficacy and safety of combined mechanical circulatory support in cardiogenic shock complicating acute myocardial infarction
Notice bibliographique
Résumé
Background Cardiogenic shock complicating acute myocardial infarction (CSAMI) is a severe complication associated with unacceptably high mortality rates. Since early revascularisation was introduced more than 20 years ago, no subsequent innovation has demonstrated conclusive efficacy in reducing mortality in CSAMI. While mechanical circulatory support (MCS) has emerged as a potential intervention, randomised controlled trials evaluating independent use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO), and intra-aortic balloon pump (IABP) have not shown benefit in CSAMI. In contrast, systematic reviews of observational studies have revealed significant mortality reduction when CSAMI was treated with combined use of MCS, specifically VA-ECMO in conjunction with a left ventricular (LV) unloading device (Impella or IABP). Combination MCS (VA-ECMO + LV unloading) may therefore present a promising approach to CSAMI, but an unresolved dilemma concerning the optimal selection between two LV unloading devices (VA-ECMO + Impella vs VA-ECMO + IABP) warrants further investigation and clarification. Purpose We perform the first systematic review and meta-analysis assessing the short-term efficacy and safety of VA-ECMO + Impella versus VA-ECMO + IABP in treatment of CSAMI. Methods A systematic search was performed on the EMBASE and MEDLINE databases. Studies reporting the short-term (30-day/inpatient) mortality and complications of adult patients with CSAMI treated with VA-ECMO + Impella and VA-ECMO + IABP were included. Fixed effect meta-analyses using Mantel-Haenszel model was used to analyse the pooled odds ratio for short-term mortality and major complications. Subgroup analysis was performed including studies with ACS predominant CS (Cause of CS 100% by AMI). Results Four observational studies meeting the predefined inclusion criteria were included in the meta-analysis, encompassing a total of 14,247 patients (1,298 treated with VA-ECMO + Impella and 12,949 treated with VA-ECMO + IABP). All studies had a fair overall quality when risk assessed by the 9-point Newcastle-Ottawa scale. The pooled analysis of short-term mortality revealed no significant difference between VA-ECMO + Impella and VA-ECMO + IABP (56.5% vs 66.5%; OR, 0.90; 95% CI, 0.79–1.02; P=0.09) (figure 1). High statistical heterogeneity was observed, indicated by an elevated I2 statistic (I286%), prompting subgroup analysis including only studies with ACS predominant CS. In this subgroup analysis, VA-ECMO + Impella demonstrated significantly lower mortality in patients with ACS predominant CS compared to VA-ECMO + IABP (53.2% vs 67.7%; OR, 0.72; 95% CI, 0.62–0.85; P<0.0001) (figure 1). However, VA-ECMO + Impella was also associated with a significantly higher risk of major bleeding (15.1% vs 8.6%; OR, 1.87; 95% CI, 1.50–2.32; P<0.00001), vascular complications (15.0% vs 6.7%; OR, 1.75; 95% CI, 1.41–2.18; P<0.00001), and new renal replacement therapy (36.5% vs 25.9%; OR, 1.65; 95% CI, 1.33–2.05; P<0.00001) compared to VA-ECMO + IABP (figure 2). Conclusions Within CSAMI patients requiring combination MCS, VA-ECMO + Impella demonstrated superior short-term mortality reduction compared to VA-ECMO + IABP within the population where AMI was the sole cause of CS. Concomitantly, VA-ECMO + Impella was associated with a greater risk of major bleeding, vascular complications, and new renal replacement therapy. Additional randomised studies are needed to validate these observational findings.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,009 | 0,027 |
| Méta-épidémiologie (sens strict) | 0,002 | 0,001 |
| Méta-épidémiologie (sens large) | 0,016 | 0,034 |
| Bibliométrie | 0,005 | 0,007 |
| Études des sciences et des technologies | 0,001 | 0,001 |
| Communication savante | 0,003 | 0,001 |
| Science ouverte | 0,002 | 0,001 |
| Intégrité de la recherche | 0,002 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,004 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».