Soh Bing Wei Thaddeus, Gracias Carlos Sebastian, Dean Afshan, Kumar Jathinder, Asgedom Solomon, Matiullah Sajjad, Owens Patrick
Department of Cardiology, University Hospital Waterford, Waterford, Ireland.
Department of Cardiology, University Hospital Limerick, Limerick, Ireland.
Catheter Cardiovasc Interv. 2025 Feb;105(3):650-661. doi: 10.1002/ccd.31369. Epub 2024 Dec 24.
Acute myocardial infarction-related cardiogenic shock (AMICS) is a severe complication associated with exceedingly high mortality rates. While mechanical circulatory support (MCS) has emerged as a potential intervention, the evidence base for independent MCS use remains weak. In contrast, systematic reviews of observational studies have revealed significant mortality reduction when a combination of MCS was used: VA-ECMO in conjunction with a left ventricular (LV) unloading device (Impella or IABP). The ongoing dilemma concerning the selection between two LV unloading devices (VA-ECMO + Impella vs. VA-ECMO + IABP) warrants further investigation and clarification.
This is 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 AMICS.
A systematic search was performed on the EMBASE, MEDLINE, and Cochrane databases. Studies reporting the short-term (30-day/inpatient) mortality and complications of adult patients with AMICS treated with VA-ECMO + Impella and VA-ECMO + IABP were included. Subgroup analysis was performed including studies with ACS predominant CS (CS etiology 100% by AMI).
Four observational studies with 14,247 patients were included. There was no significant difference in mortality 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). However, VA-ECMO + Impella was associated with significantly lower mortality in patients with ACS predominant CS (53.2% vs. 67.7%; OR, 0.72; 95% CI, 0.62-0.85; p < 0.0001). VA-ECMO + Impella was concomitantly associated with a significantly higher risk of complications.
When comparing LV unloading devices in patients with AMICS requiring a combination of MCS, VA-ECMO + Impella was superior in mortality reduction only in the cohort where 100% of CS was caused by AMI.
急性心肌梗死相关的心源性休克（AMICS）是一种严重并发症，死亡率极高。虽然机械循环支持（MCS）已成为一种潜在的干预措施，但独立使用MCS的证据基础仍然薄弱。相比之下，对观察性研究的系统评价显示，联合使用MCS时死亡率显著降低：VA-ECMO联合左心室（LV）卸载装置（Impella或IABP）。在两种LV卸载装置（VA-ECMO + Impella与VA-ECMO + IABP）之间进行选择时，目前存在的困境值得进一步研究和阐明。
这是第一项系统评价和荟萃分析，评估VA-ECMO + Impella与VA-ECMO + IABP治疗AMICS的短期疗效和安全性。
对EMBASE、MEDLINE和Cochrane数据库进行系统检索。纳入报告VA-ECMO + Impella和VA-ECMO + IABP治疗的成年AMICS患者短期（30天/住院）死亡率和并发症的研究。进行亚组分析，包括以急性冠状动脉综合征为主的心源性休克（CS病因100%为AMI）的研究。
纳入四项观察性研究，共14247例患者。VA-ECMO + Impella与VA-ECMO + IABP的死亡率无显著差异（56.5%对66.5%；OR，〇.9〇；95%CI，〇.79-1.〇2；P = 〇.〇9）。然而，在以急性冠状动脉综合征为主的心源性休克患者中，VA-ECMO + Impella的死亡率显著较低（53.2%对67.7%；OR，〇.72；95%CI，〇.62-〇.85；P < 〇.〇〇〇1）。VA-ECMO + Impella同时与显著更高的并发症风险相关。
在需要联合MCS治疗的AMICS患者中比较LV卸载装置时，VA-ECMO + Impella仅在CS 100%由AMI引起的队列中在降低死亡率方面更具优势。
