46 A systematic review and meta-analysis of the efficacy and safety of combined mechanical circulatory support in cardiogenic shock complicating acute myocardial infarction
Bibliographic record
Abstract
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.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.009 | 0.027 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.016 | 0.034 |
| Bibliometrics | 0.005 | 0.007 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.001 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.004 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".