Implementation of extracorporeal membrane oxygenation before primary percutaneous coronary intervention may improve the survival of patients with ST-segment elevation myocardial infarction and refractory cardiogenic shock. (15th October 2018) - Huang, Chi-Cheng
Abstract: Background: The mortality of patients with ST-segment elevation myocardial infarction (STEMI) and refractory cardiogenic shock (RCS) is high. Extracorporeal membrane oxygenation (ECMO) before percutaneous coronary intervention (PCI) has shown some favorable results, but this may delay door-to-balloon (D2B) time. Whether the benefit surpasses the risk of longer D2B time remains controversial. Methods: From January 2005 to December 2014, there were 46 patients with STEMI RCS who received ECMO and PCI. Comparison was made between patients whose ECMO were setup before ( n = 12) and after ( n = 34) the coronary angiography. Results: There were no significant differences on the baseline characteristics. The ECMO before PCI group had significantly better six-month survival (58.3% vs. 14.7%, p = 0.006), and the benefit persisted to the end of two-year follow-up (41.7% vs. 11.8%, p = 0.045). The rates of neurological, vascular, or bleeding complications were not different between the groups. ECMO before PCI was associated with a nonsignificant increase of median D2B time (30 min) and decrease of patients achieving D2B time < 90 min (9.1% vs. 32.0%). After adjusting for GRACE score, gender, D2B time, complete revascularization, ECMO before PCI and shock index < 0.8 before PCI were significantly associated with six-month survival. Conclusions: In STEMI RCS patients, ECMO before PCI improves both short- and long-term outcomes, even if it nonsignificantly increases the D2B time. Our data suggests that ECMO before PCI is a reasonable and safe strategy in this particularly-ill population. Highlights: ECMO before PCI improves the survival of STEMI patients with refractory cardiogenic shock. Early ECMO nonsignificantly delays door-to-balloon time, but the benefit easily outweighs the harm. Patients with a shock index ≥0.8 upon arrival and respond poorly to inotropes are most likely to benefit from early ECMO.