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Review
. 2022 May;27(3):927-934.
doi: 10.1007/s10741-021-10092-y. Epub 2021 Mar 6.

Mechanical circulatory support in patients with cardiogenic shock not secondary to cardiotomy: a network meta-analysis

Stefano Benenati  1   2 , Matteo Toma  1   2 , Claudia Canale  1   2 , Rocco Vergallo  3 , Roberta Della Bona  1 , Davide Ricci  4   5 , Marco Canepa  1   2 , Gabriele Crimi  1 , Francesco Santini  4   5 , Pietro Ameri  6   7 , Italo Porto  1   2
Affiliations
Review

Mechanical circulatory support in patients with cardiogenic shock not secondary to cardiotomy: a network meta-analysis

Stefano Benenati et al. Heart Fail Rev. 2022 May.

Abstract

To compare the efficacy and safety of different mechanical circulatory support (MCS) devices in CS. A total of 24 studies (7 randomized controlled trials-RCTs-and 17 non-RCTs) involving 11,117 patients were entered in a Bayesian network meta-analysis. The primary endpoint was 30-day mortality. Secondary endpoints were stroke and bleeding (requiring transfusion and/or intracranial and/or fatal). Compared with no MCS, extra-corporeal membrane oxygenation (ECMO) reduced 30-day mortality when used both alone (OR 0.37, 95% CrI 0.15-0.90) and together with the micro-axial pump Impella (OR 0.13, 95% CrI 0.02-0.80) or intra-aortic balloon pump (IABP) (OR 0.19, 95% CrI 0.05-0.63), although the relevant articles were affected by significant publication bias. Consistent results were obtained in a sensitivity analysis including only studies of CS due to myocardial infarction. After halving the weight of studies with a non-RCT design, only the benefit of ECMO + IABP on 30-day mortality was maintained (OR 0.22, 95% CI 0.057-0.76). The risk of bleeding was increased by TandemHeart (OR 13, 95% CrI 3.50-59), Impella (OR 5, 95% CrI 1.60-18), and IABP (OR 2.2, 95% CrI 1.10-4.4). No significant differences were found across MCS strategies regarding stroke. Although limited by important quality issues, the studies performed so far indicate that ECMO, especially if combined with Impella or IABP, reduces short-term mortality in CS. MCS increases the hazard of bleeding.

Keywords: Cardiogenic shock; Extracorporeal membrane oxygenation; Impella; Intra-aortic balloon pump; Mechanical circulatory support; TandemHeart.

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Conflict of interest statement

Dr. Ameri reports personal fees from Novartis, personal fees from Astra Zeneca, personal fees from Vifor, personal fees from Daiichi-Sankyo, personal fees from Boehringer Ingelheim, personal fees from Janssen, personal fees from Merck Sharp & Dohme, and personal fees from GlaxoSmithKline, outside the submitted work; Dr. Porto reports grants and personal fees from AstraZeneca, personal fees from Daiichi Sankyo, personal fees from Terumo Corporation, personal fees from Biotronik, personal fees from Bayer, personal fees from Amgen, and personal fees and non-financial support from Abiomed, outside the submitted work; Dr. Canepa reports grants and personal fees from Pfizer, personal fees from Novartis, personal fees from Akcea Therapeutics, and personal fees from Sanofi Genzyme, outside the submitted work; Dr. Crimi reports personal fees from Philips healthcare, outside the submitted work; other authors have nothing to disclose.

Figures

Fig. 1
Fig. 1
Analysis of 30-day mortality. a Treatments network. Each treatment is represented by a colored circle (node) of size proportional to the number of studies in which it was evaluated. The number of patients receiving each treatment is reported in parentheses. b Forest plot. Reference is “no MCS”, whereas comparators are shown on the left part of the panel. c Treatment ranking according to SUCRA values. Red bars indicate SUCRA values on a scale from 0 to 1. Longer bars (i.e., higher SUCRA values) indicate better-performing treatment. Abbreviations: CrI credible interval, ECMO extra-corporeal membrane oxygenation, IABP intra-aortic balloon pump, MCS mechanical circulatory support
Fig. 2
Fig. 2
Forest plots for bleeding and stroke. Reference is “no MCS,” whereas comparators are shown on the left part of the figure. When the upper limit of the credible interval (CrI) exceeds the scale of the plot, an arrow is displayed. Abbreviations: OR odds ratio, ECMO extra-corporeal membrane oxygenation, IABP intra-aortic balloon pump
See this image and copyright information in PMC

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