Background:Although there is an increase in the use of mechanical circulatory support devices to rescue patients with acute myocardial infarction (AMI) complicated by refractory cardiogenic shock (CS), the optimal timing of the application remains controversial. Therefore, this study aimed to compare the clinical outcomes between venoarterial-extracorporeal membrane oxygenation (VA-ECMO) insertion before and after coronary revascularization in AMI patients with refractory CS.

Methods and Results:A total of 253 patients with AMI who underwent revascularization therapy with VA-ECMO were included. The study population was stratified into extracorporeal cardiopulmonary resuscitation (E-CPR) before revascularization (N=106, reference cohort) and refractory CS without E-CPR before revascularization (n=147, comparison cohort). Patients with refractory CS but without E-CPR before revascularization were further divided into VA-ECMO before revascularization (N=50) and VA-ECMO after revascularization (n=97). The primary endpoint was a composite of in-hospital mortality, left ventricular assist device implantation, and heart transplantation. The primary endpoint occurred in 60 patients (40.8%) of the comparison cohort and 51 patients (48.1%) of the reference cohort. Among the comparison cohort, the primary endpoint was significantly lower in VA-ECMO before revascularization than in VA-ECMO after revascularization (32.0% vs. 49.5%, OR 0.480, 95% CI 0.235–0.982, P=0.045). A similar trend was observed after a 1-year follow up.

Conclusions:Early initiation of VA-ECMO before revascularization therapy might improve clinical outcomes in patients with AMI complicated by refractory CS.

背景：尽管使用机械循环支持装置来拯救急性心肌梗死 (AMI) 并发难治性心源性休克 (CS) 患者的情况有所增加，但应用的最佳时机仍存在争议。因此，本研究旨在比较 AMI 难治性 CS 患者冠状动脉血运重建前后静脉-动脉-体外膜肺氧合 (VA-ECMO) 插入的临床结果。

方法和结果：共纳入 253 名接受 VA-ECMO 血运重建治疗的 AMI 患者。研究人群被分为血运重建前的体外心肺复苏 (E-CPR)（N=106，参考队列）和血运重建前未进行 E-CPR 的难治性 CS（n=147，对比队列）。血运重建前未行 E-CPR 的难治性 CS 患者进一步分为血运重建前 VA-ECMO（N=50）和血运重建后 VA-ECMO（n=97）。主要终点是住院死亡率、左心室辅助装置植入和心脏移植的复合终点。主要终点发生在比较队列的 60 名患者 (40.8%) 和参考队列的 51 名患者 (48.1%) 中。在比较队列中，血运重建前 VA-ECMO 的主要终点显着低于血运重建后 VA-ECMO（32.0% vs. 49.5%，OR 0.480，95% CI 0.235–0.982，P=0.045）。在 1 年的随访后观察到类似的趋势。

结论：在血运重建治疗前早期开始 VA-ECMO 可能会改善 AMI 合并难治性 CS 患者的临床结果。