Venoarterial ECMO may not reduce mortality in patients with infarct-related cardiogenic shock

A recent study published in The Lancet has concluded that VA-ECMO did not decrease the 30-day mortality rate in individuals with cardiogenic shock related to infarct, and a rise in severe bleeding and vascular complications was documented by the team of researchers in this study.

Despite the lack of scientific evidence from adequately powered randomized clinical trials, the use of VA-ECMO in patients with cardiogenic shock has increased. Three trials reported so far were underpowered to detect a survival benefit. There needs to be data based on individual patient-based meta-analyses to determine the impact of VA-ECMO on 30-day death rates. This background was studied in the present study.

Researchers searched MEDLINE, Cochrane Central Register of Controlled Trials and Embase. They identified RCTs comparing early routine use of VA-ECMO versus optimal medical therapy alone in patients presenting with infarct-related cardiogenic shock.

The primary outcome was determined as Odds ratios (ORs) pooled using logistic regression models.

Key findings from this study are:

• Four trials were identified.
• There were 567 patients, 284 in VA-ECMO and 283 in control.
• With the early use of VA-ECMO, there was no significant reduction in the 30-day death rate with OR 0·93.
• Relating to major bleeding and peripheral ischaemic vascular complications, the rates of complication were higher with VA-ECMO with OR 2.44 and 3.53, respectively.
• Prespecified subgroup analyses were consistent. They did not show any benefit for VA-ECMO.

Interpreting further, they said, “Based on the results of our study, VA-ECMO did not reduce the 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock.”

We noted an increase in major bleeding and vascular complication, they wrote. A careful review of the indication for VA-ECMO in this setting is warranted.

As acknowledged, the Foundation Institut für Herzinfarktforschung funded the study.

Reference:

Zeymer et al. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomized trials. The Lancet, 402(10410), 1338–1346. https://doi.org/10.1016/s0140-6736(23)01607-0