VA-ECMO for infarct-related cardiogenic shock
Authors: Ya Gao, Zhifan Li, Ming Liu, Jinhui Tian
Journal: The Lancet (2024)

Uwe Zeymer and colleagues1Zeymer U Freund A Hochadel M et al.Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials.Lancet. 2023; 402: 1338-1346Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar conducted an individual patient data meta-analysis examining the effect of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with infarct-related cardiogenic shock. Although their methodology is well established, their interpretation of the findings appears to primarily hinge upon relative effects, neglecting to consider the certainty of evidence and absolute effects. Failing to consider certainty of evidence during meta-analysis interpretation can yield misleading conclusions. We adopted the GRADE approach to assess the certainty of evidence.2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar We chose the minimally important difference (MID) as a threshold to assess imprecision of the pooled estimate and set MID for all-cause death at day 30 as 1%. Due to the 95% CI crossing both sides of the MID decision threshold, we downgraded two levels for imprecision and thus obtained low certainty of evidence (appendix). To calculate absolute effects, we applied the median all-cause death at day 30 from the control groups in the included studies as the baseline risk (440 per 1000 patients). Incorporating the absolute effect and certainty of evidence can provide more comprehensive insights into the results. VA-ECMO compared with control interventions might have little or no differences in all-cause death at day 30 (risk difference 1·8% fewer, 95%CI –9·9% to 6·3%; appendix). However, due to the low certainty of evidence, the authors cannot provide a solid conclusion and their findings necessitate validation through further studies. Furthermore, it is important to consider the credibility of results from their subgroup analyses.3Schandelmaier S Briel M Varadhan R et al.Development of the Instrument to assess the Credibility of Effect Modification Analyses (ICEMAN) in randomized controlled trials and meta-analyses.CMAJ. 2020; 192: e901-e906Crossref PubMed Scopus (250) Google Scholar Between-trial subgroup analyses introduce ecological bias, which risks misleading conclusions.4Fisher DJ Carpenter JR Morris TP Freeman SC Tierney JF Meta-analytical methods to identify who benefits most from treatments: daft, deluded, or deft approach?.BMJ. 2017; 356: j573Crossref PubMed Scopus (141) Google Scholar Incorporating within-trial subgroup analysis can be invaluable in discerning genuine subgroup effects. We declare no competing interests. Download .pdf (.13 MB) Help with pdf files Supplementary appendix Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trialsVA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted. Full-Text PDF