Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies.

Ryan Ruiyang Ling, Shir Lynn Lim, Kollengode Ramanathan, Kiran Shekar, Graeme MacLaren, Susanna Price, Chuen Seng Tan, Bram Rochwerg, Daniel Brodie, Alain Combes, Christopher Jer Wei Low, Michele Petrova Xin Ling Lau, Nigel Sheng Hui Liu, Melissa Tan

Journal: Intensive care medicine 2024;50(2):209-221

PMID: 38206381

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Abstract

PURPOSE

Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit.

METHODS

We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model.

RESULTS

We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66).

CONCLUSION

In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.

Address: Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.; Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.; Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.; Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore.; Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.; Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore.; Duke-NUS Medical School, Pre-Hospital and Emergency Research Center, Singapore, Singapore.; Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.; Service de Médecine Intensive-RéanimationInstitut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France.; UMRS 116, Institute of Cardio Metabolism and Nutrition, Sorbonne Universite INSERM, Paris, France.; Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.; Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia.; Queensland University of Technology, Gold Coast, QLD, Australia.; University of Queensland, Gold Coast, QLD, Australia.; Bond University, Gold Coast, QLD, Australia.; Royal Brompton and Harefield Hospitals, London, UK.; National Heart and Lung Institute, Imperial College, London, UK.; Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.; Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.; Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore. [email protected].; Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore. [email protected].

DOI: 10.1007/s00134-023-07278-3

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https://dx.doi.org/10.1007/s00134-023-07278-3

MeSH Terms: Humans, Shock, Cardiogenic, Propensity Score, Randomized Controlled Trials as Topic, Heart-Assist Devices