Clinical use and impact of mechanical circulatory support for myocardial infarction-related cardiogenic shock in the Netherlands: a registry-based propensity-matched analysis

Abstract

Background: Despite limited beneficial evidence, mechanical circulatory support (MCS) is commonly used in patients with acute myocardial infarction-related cardiogenic shock (AMI-CS). In this Dutch registry, we investigated MCS usage, associated patient characteristics and clinical outcomes.

Methods: This real-world, multicentre registry included CS patients undergoing percutaneous coronary intervention between 2017 and 2021 in 14 Dutch hospitals. The impact on clinical outcomes was analysed after 1:1 average propensity-score (aPS) matching.

Results: This AMI-CS registry included 2217 patients with a mean age of 66.4 (±12.3) years and predominantly male (72.8%, n=1613). MCS was deployed in 516 patients (23.3%), of which the intra-aortic balloon pump was used most frequently (n=253, 49.0%). Impella was used in 94 patients (18.2%), extracorporeal membrane oxygenation in 68 patients (13.2%) and 95 patients (18.4%) received multiple devices. Patients receiving MCS were younger (64.2 vs 67.0, p<0.01), presented with lower mean arterial pressures (74.7 vs 78.4 mm Hg, p<0.01), higher heart rates (88.3 vs 81.7 beats per minute, p<0.01) and higher initial lactate levels (6.4 vs 5.4 mmol/L, p<0.01). The percentage of resuscitated patients was comparable among MCS and non-MCS patients (38.6% vs 42.2%, p=0.17). The 30-day mortality rate was higher in MCS patients (55.0% vs 34.7%, p<0.01). After aPS-matching (n=970), 30-day mortality remained higher for MCS patients (53.8% vs 44.7%, p<0.01), with an associated OR of 1.44 (95% CI 1.12 to 1.85, p<0.01).

Conclusions: Despite limited evidence, MCS was used in a fourth of all AMI-CS patients. MCS usage was associated with an increased 30-day mortality in this real-world setting, even after propensity-matching.

Keywords: Heart Failure, Systolic; Heart-Assist Devices; Myocardial Infarction; Percutaneous Coronary Intervention.

Figure 1. Study flow chart. AMI, acute myocardial infarction; MCS, mechanical circulatory support; (N)STEMI, (non-)ST-elevated myocardial infarction.

Figure 2. Use of MCS devices. ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; MCS, mechanical circulatory support.

Figure 3. (A) Kaplan-Meier curve of the unmatched cohort. (B) Kaplan-Meier curve of the matched cohort. MCS, mechanical circulatory support.

Figure 4. Association between mechanical circulatory support (MCS) use and 30-day mortality in subgroups of interest from the matched study. The p-value represents the interaction p-value. BMI, body mass index; LM, left main; MVD, multivessel disease; OHCA, out-of-hospital cardiac arrest; PCI, percutaneous coronary intervention; (N)STEMI, (non-)ST-elevated myocardial infarction.