Gédéon Tara, Zolotarova Tetiana, Eisenberg Mark J
Division of Cardiology, Jewish General Hospital, McGill University, 3755 Côte Ste-Catherine Road, Suite H-421.1, Montreal, QC H3T 1E2, Canada.
Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte Ste-Catherine Road, Montreal, QC H3T 1E2, Canada.
Eur Heart J Open. 2024 Jun 16;4(4):oeae051. doi: 10.1093/ehjopen/oeae051. eCollection 2024 Jul.
Cardiogenic shock (CS) develops in up to 10% of patients with acute myocardial infarction (AMI) and carries a 50% risk of mortality. Despite the paucity of evidence regarding its benefits, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in clinical practice in patients with AMI in CS (AMI-CS). This review aims to provide an in-depth description of the four available randomized controlled trials to date designed to evaluate the benefit of VA-ECMO in patients with AMI-CS.
The literature search was conducted on PubMed, Google Scholar, and clinicaltrials.gov to identify the four relevant randomized control trials from years of inception to October 2023. Despite differences in patient selection, nuances in trial conduction, and variability in trial endpoints, all four trials (ECLS-SHOCK I, ECMO-CS, EUROSHOCK, and ECLS-SHOCK) failed to demonstrate a mortality benefit with the use of VA-ECMO in AMI-CS, with high rates of device-related complications. However, the outcome of these trials is nuanced by the limitations of each study that include small sample sizes, challenging patient selection, and high cross-over rates to the intervention group, and lack of use of left ventricular unloading strategies.
The presented literature of VA-ECMO in CS does not support its routine use in clinical practice. We have yet to identify which subset of patients would benefit most from this intervention. This review emphasizes the need for designing adequately powered trials to properly assess the role of VA-ECMO in AMI-CS, in order to build evidence for best practices.
心源性休克（CS）在高达10%的急性心肌梗死（AMI）患者中发生，死亡率达50%。尽管关于其益处的证据不足，但静脉-动脉体外膜肺氧合（VA-ECMO）在CS的AMI（AMI-CS）患者的临床实践中使用越来越多。本综述旨在深入描述迄今为止四项可用的随机对照试验，这些试验旨在评估VA-ECMO对AMI-CS患者的益处。
在PubMed、谷歌学术和clinicaltrials.gov上进行文献检索，以确定从试验开始到2023年10月的四项相关随机对照试验。尽管在患者选择、试验实施细节和试验终点方面存在差异，但所有四项试验（ECLS-SHOCK I、ECMO-CS、EUROSHOCK和ECLS-SHOCK）均未证明在AMI-CS中使用VA-ECMO可降低死亡率，且与设备相关的并发症发生率很高。然而，这些试验的结果因每项研究的局限性而存在细微差别，包括样本量小、患者选择具有挑战性、干预组的交叉率高以及未使用左心室卸载策略。
目前关于VA-ECMO用于CS的文献不支持其在临床实践中的常规使用。我们尚未确定哪类患者亚组能从这种干预中获益最大。本综述强调需要设计有足够效力的试验，以正确评估VA-ECMO在AMI-CS中的作用，从而为最佳实践积累证据。
