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

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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.

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Availability of data and materials

All data generated or analyzed during this study are included in the published studies and their supplementary information files.

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Acknowledgements

The authors acknowledge Suei Nee Wong for her assistance with the search strategy, and Chan Yiong Huak for his expertise on the statistical analysis of this project. We dedicate this manuscript to Chuen Seng Tan, who sadly passed away on 25th May 2023.

Funding

There was no funding source for this study.

Author information

Author notes

  1. Christopher Jer Wei Low and Ryan Ruiyang Ling have contributed equally to the submission of this manuscript.

Authors and Affiliations

  1. Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore

    Christopher Jer Wei Low, Ryan Ruiyang Ling, Michele Petrova Xin Ling Lau, Nigel Sheng Hui Liu, Chuen Seng Tan, Shir Lynn Lim, Graeme MacLaren & Kollengode Ramanathan

  2. Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore

    Melissa Tan, Graeme MacLaren & Kollengode Ramanathan

  3. Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore

    Chuen Seng Tan

  4. Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore

    Shir Lynn Lim

  5. Duke-NUS Medical School, Pre-Hospital and Emergency Research Center, Singapore, Singapore

    Shir Lynn Lim

  6. Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada

    Bram Rochwerg

  7. Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada

    Bram Rochwerg

  8. Service de Médecine Intensive-RéanimationInstitut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France

    Alain Combes

  9. UMRS 116, Institute of Cardio Metabolism and Nutrition, Sorbonne Universite INSERM, Paris, France

    Alain Combes

  10. Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA

    Daniel Brodie

  11. Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia

    Kiran Shekar

  12. Queensland University of Technology, Gold Coast, QLD, Australia

    Kiran Shekar

  13. University of Queensland, Gold Coast, QLD, Australia

    Kiran Shekar

  14. Bond University, Gold Coast, QLD, Australia

    Kiran Shekar

  15. Royal Brompton and Harefield Hospitals, London, UK

    Susanna Price

  16. National Heart and Lung Institute, Imperial College, London, UK

    Susanna Price

Authors
  1. Christopher Jer Wei Low
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Contributions

Study design: RRL, CJWL, KR. Search strategy and screening of articles: CJWL, RRL, MPXLL, NSHL, MT, KR. Risk of bias assessment: CJWL, RRL, MPXLL, NSHL, MT, KR. Data collection: CJWL, RRL, MPXLL, NSHL, MT, KR. Data analysis and interpretation: CJWL, RRL, CST, BR, KR. Tables and figures: CJWL, RRL, MPXLL, NSHL, MT. Drafting of manuscript: CJWL, RRL. Critical revision of manuscript for important intellectual content: CJWL, RRL, MPXLL, NSHL, MT, SLL, BR, AC, KS, GM, KR. All authors provided critical conceptual input, interpreted the data analysis, read, and approved the final draft. CJWL, RRL, MPXLL, NSHL, MT, KR have accessed and verified the data. CJWL, RRL, and KR were responsible for the decision to submit the manuscript.

Corresponding author

Correspondence to Kollengode Ramanathan.

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Conflicts of interest

RRL receives research support from the Clinician Scientist Development Unit, Yong Loo Lin School of Medicine, National University of Singapore. SLL receives support from the National Medical Research Council Transitional Award (MOH-001146) and National University Health System Clinician Scientist Program; she has received research grants from Zoll Foundation, National University Health System, National Kidney Foundation of Singapore and Singapore Heart Foundation. AC receives personal fees from Getinge, Xenios, and Baxter International Inc. He serves on the Executive Committee and Scientific Committee of ECMONet, and is Past-President of the European Extracorporeal Life Support Organization (EuroELSO). DB receives research support from and consults for LivaNova. He has been on the medical advisory boards for Abiomed, Xenios, Medtronic, Inspira and Cellenkos. He is the President-elect of ELSO and the Chair of the Executive Committee of the International ECMO Network (ECMONet), and he writes for UpToDate. KS serves on the Scientific Committee and Network Committee of ECMONet. He reports receiving lecture honoraria outside of the submitted work from Getinge and Abiomed. GM is the President of ELSO. KR is part of the steering committee of ELSO, and serves as the chair of its Publication Committee. He is the past co-chair of the Scientific Oversight Committee. . He has received honoraria from Xenios for educational lectures on ECMO. All other authors declare no competing interests.

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Low, C.J.W., Ling, R.R., Lau, M.P.X.L. et al. Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies. Intensive Care Med 50, 209–221 (2024). https://doi.org/10.1007/s00134-023-07278-3

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