Debate: ECMO in patients with cardiogenic shock due to myocardial infarction. A researcher’s perspective

Abstract

Acute myocardial infarction-related cardiogenic shock (AMI-CS) carries a dismal prognosis. Short-term mortality is in the range of 40% to 50%.1 Until recently, only percutaneous coronary intervention of the culprit lesion reduced mortality within randomized controlled trials (RCT).1 More recently, the active microaxial flow pump showed a mortality reduction at 6-month follow-up in the Danish German Shock trial (DanGer-Shock).2 However, this RCT was performed in a highly selected group of patients with ST-elevation myocardial infarction only and excluded patients with possible hypoxic brain injury.2 In addition, it remains unclear whether the positive results were influenced by: a) device design (loading vs unloading of the left ventricle), b) patient selection, and c) treatment bias.3 High expectations have also been placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO), and its use has risen exponentially by up to 40 times in the last decade despite a lack of relevant evidence from RCTs.4 In contrast to microaxial flow pumps, the concept of VA-ECMO is to provide temporary complete circulatory and respiratory support during the critical first days as a bridge-to-recovery, bridge-to-decision, bridge-to-durable left ventricular assist device (LVAD), or bridge-to-transplantation. QUESTION: What evidence exists for the use of ECMO in cardiogenic shock due to a myocardial infarction? ANSWER: The evidence...