Meta-Analysis
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jan 26, 2016; 8(1): 98-111
Published online Jan 26, 2016. doi: 10.4330/wjc.v8.i1.98
Percutaneous assist devices in acute myocardial infarction with cardiogenic shock: Review, meta-analysis
Francesco Romeo, Maria Cristina Acconcia, Domenico Sergi, Alessia Romeo, Simona Francioni, Flavia Chiarotti, Quintilio Caretta
Francesco Romeo, Domenico Sergi, Alessia Romeo, Department of Cardiovascular Disease, University of Rome - Tor Vergata, 00133 Rome, Italy
Maria Cristina Acconcia, Department of Cardiovascular Disease, University of Rome - La Sapienza, 00161 Rome, Italy
Simona Francioni, Center for Biomedical Technology and Integrated Department Services to Education, University of Florence, 50134 Florence, Italy
Flavia Chiarotti, Department of Cell Biology and Neuroscience, Italian National Institute of Health, 00161 Rome, Italy
Quintilio Caretta, Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
Author contributions: Romeo F and Caretta Q contributed equally to conception and design of the study, to the revision for important intellectual content, to interpretation of data for the manuscript and wrote the paper; Acconcia MC contributed to conception and design of the study, participated in data collection, analyzed the data and wrote data analysis and findings; Sergi D, Romeo A and Francioni S performed the research, collected data and revised drafts of the paper; Chiarotti F contributed to conception and design of the study, participated in data analysis, wrote data analysis and findings; all authors discussed the results and implications and commented on the manuscript at all stages, read and approved the final manuscript.
Conflict-of-interest statement: The authors deny any conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Quintilio Caretta, MD, Associate Professor, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy. qcaretta@unifi.it
Telephone: +39-34-87809379 Fax: +39-06-20904008
Received: June 23, 2015
Peer-review started: June 24, 2015
First decision: August 25, 2015
Revised: September 19, 2015
Accepted: November 10, 2015
Article in press: November 11, 2015
Published online: January 26, 2016
Processing time: 212 Days and 8.9 Hours
Abstract

AIM: To assess the impact of percutaneous cardiac support in cardiogenic shock (CS) complicating acute myocardial infarction (AMI), treated with percutaneous coronary intervention.

METHODS: We selected all of the studies published from January 1st, 1997 to May 15st, 2015 that compared the following percutaneous mechanical support in patients with CS due to AMI undergoing myocardial revascularization: (1) intra-aortic balloon pump (IABP) vs Medical therapy; (2) percutaneous left ventricular assist devices (PLVADs) vs IABP; (3) complete extracorporeal life support with extracorporeal membrane oxygenation (ECMO) plus IABP vs IABP alone; and (4) ECMO plus IABP vs ECMO alone, in patients with AMI and CS undergoing myocardial revascularization. We evaluated the impact of the support devices on primary and secondary endpoints. Primary endpoint was the inhospital mortality due to any cause during the same hospital stay and secondary endpoint late mortality at 6-12 mo of follow-up.

RESULTS: One thousand two hundred and seventy-two studies met the initial screening criteria. After detailed review, only 30 were selected. There were 6 eligible randomized controlled trials and 24 eligible observational studies totaling 15799 patients. We found that the inhospital mortality was: (1) significantly higher with IABP support vs medical therapy (RR = +15%, P = 0.0002); (2) was higher, although not significantly, with PLVADs compared to IABP (RR = +14%, P = 0.21); and (3) significantly lower in patients treated with ECMO plus IABP vs IABP (RR = -44%, P = 0.0008) or ECMO (RR = -20%, P = 0.006) alone. In addition, Trial Sequential Analysis showed that in the comparison of IABP vs medical therapy, the sample size was adequate to demonstrate a significant increase in risk due to IABP.

CONCLUSION: Inhospital mortality was significantly higher with IABP vs medical therapy. PLVADs did not reduce early mortality. ECMO plus IABP significantly reduced inhospital mortality compared to IABP.

Keywords: Intra-aortic balloon pump; Impella; TandemHeart; Extracorporeal membrane oxygenation; Cardiogenic shock; Meta-analysis

Core tip: Meta-analyses from observational studies represent an area of innovation in statistical science. In the present review, we identified only a small number of randomized trials, which by themselves were underpowered to assess the efficacy of the support devices on inhospital mortality. To increase the power of the analysis we included observational data, which enabled us to add 14909 additional patients to the 890 from the randomized controlled trials selected. The results of the analysis showed that: (1) intra-aortic balloon pump (IABP) used alone was associated with significant increase in inhospital mortality compared to Medical therapy; (2) percutaneous left ventricular assist devices increased, although non significantly, the mortality as compared with IABP; and (3) extracorporeal membrane oxygenation (ECMO) plus IABP had significant protective effect compared to IABP or ECMO alone.