No benefit of extracorporeal life support in MI plus cardiogenic shock

The addition of extracorporeal life support (ECLS) to standard medical therapy did not reduce all-cause mortality in patients with acute myocardial infarction (MI) and cardiogenic shock, challenging current guideline recommendations.

“Although the use of ECLS has been increasing in the context of treating infarct-related cardiogenic shock, there is insufficient evidence for its effect on mortality,” explained Prof. Holger Thiele (University of Leipzig, Germany) [1]. To evaluate ECLS in this setting, the ECLS-SHOCK trial (NCT03637205) randomised 420 patients with acute MI complicated by cardiogenic shock 1:1 to ECLS plus standard medical therapy or standard medical therapy only [2]. The primary endpoint was 30-day all-cause mortality.

No significant difference was observed in all-cause mortality between the ECLS arm and the control arm (47.8% vs 49.0%; RR 0.98; 95% CI 0.80–1.19; P=0.81). Prof. Thiele added that secondary outcomes such as arterial lactate, renal function, and simplified acute physiology score (SAPS II) confirmed that there was no difference between both treatment groups. However, there was an increased risk for moderate-to-severe bleeding in participants receiving ECLS compared with those in the control arm (23.4% vs 9.6%; RR 2.44; 95% CI 1.50–3.95; P<0.05). Similarly, the ECLS arm showed higher rates of peripheral ischaemic vascular complications requiring surgical or interventional therapy (11.0% vs 3.8%; RR 2.86; 95% CI 1.31-6.25; P<0.05).

The authors also performed a meta-analysis of the 4 trials investigating ECLS in this setting (i.e. ECLS-SHOCK 1, ECMO-CS, EURO SHOCK, and ECLS-SHOCK) and found no effect on all-cause mortality by omitting this therapy (OR 0.93; 95% CI 0.66–1.29) [3].

In conclusion, both the current ECLS-SHOCK trial and a meta-analysis including 4 randomised-controlled trials comparing ECLS to control failed to show that an ECLS strategy reduces all-cause mortality or other endpoints in patients with acute MI and cardiogenic shock. However, there was an increased bleeding rate in patients who were treated with ECLS. These findings question current guideline recommendations and the increasing use of mechanical circulatory support in patients with cardiogenic shock in clinical practice. These results question the recommendations of the current guidelines and suggest that ECLS should be used with restraint in patients after MI and complicating cardiogenic shock.

1. Thiele H, et al. Extracorporeal life support for acute myocardial infarction complicated by cardiogenic shock: ECLS-SHOCK. Hot Line Session 3, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
2. Thiele H, et al. N Engl J Med. 2023; Aug 26. DOI: 10.1056/NEJMoa2307227.
3. Zeymer U, et al. Lancet. 2023; Aug 26. DOI: 10.1016/S0140-6736(23)01607-0.

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Posted on 30 October 202330 October 2023