Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable.
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable.
CoSTR Citation
Scquizzato T, Shannon Fernando, Brian Grunau, Sonia D’Arrigo, Yew Woon Chia, Carrie Leong, Markus Skrifvars, on behalf of the International Liaison Committee on Resuscitation Advanced Life Support Task Force. Mechanical circulatory support after return of spontaneous circulation following cardiac arrest Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2024 October 21. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review (PROSPERO CRD42024566810) conducted by the ILCOR ALS TF with involvement of clinical content experts. Evidence for adult literature was sought and considered by the Advanced Life Support Task Force. These data were taken into account when formulating the Treatment Recommendations.
We would like to thank the investigators of the DanGer Shock (Moller et al.), ECLS-SHOCK (Brunner et al), and IMPRESS (Ouweneel et al) trials for providing additional data.
Systematic Review
Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults with cardiogenic shock after return of spontaneous circulation (ROSC) following cardiac arrest in any setting (in-hospital or out-of-hospital).
Intervention: Management with a mechanical circulatory support device.
Comparators: Management without a mechanical circulatory support device or usual post-resuscitation care
Outcomes: Primary outcome: survival at hospital discharge/30 days, and at the time of the longest follow-up. Secondary outcomes: favorable neurological outcome, quality of life, length of hospital and ICU stay, adverse events/complications (e.g., bleeding, limb ischemia, arrhythmias, recurrent cardiac arrest, acute kidney injury +/- renal replacement therapy, stroke, hemolysis) as defined by study authors.
Study Designs: Randomized controlled trials (RCTs) were included.
Non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case-control studies, unpublished studies, conference abstracts, trial protocols, editorials, comments, and letters to the editor) were excluded.
Animal studies were also excluded.
Studies were a MCS device was initiated during ongoing CPR (i.e., extracorporeal cardiopulmonary resuscitation) were not considered.
All relevant publications in any language were included if there was an English abstract or full-text article available.
Timeframe: There was no limitation on publication period.
Literature search updated to July 3, 2024.
PROSPERO Registration CRD42024566810 on July 18, 2024
Consensus on Science
For the critical outcome of survival at 30 days/hospital discharge, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 13 randomized trials enrolling 1842 patients with cardiogenic shock (64% [95% confidence interval (CI), 45-80] were resuscitated from cardiac arrest)1–13 showing no difference between treatment with a mechanical circulatory support device and standard care (odds ratio [OR] 1.16 [95% CI, 0.97–1.40]), or 37 more survivors per 1,000 patients [95% CI, from 8 fewer to 82 more]).
We identified or obtained data for the subgroup of patients with cardiac arrest from 6 randomized trials enrolling 766 patients resuscitated after cardiac arrest5–8,12,14 and found no difference between treatment with a mechanical circulatory support device and standard care (OR 0.97 [95% CI, 0.73–1.30], or 8 fewer survivors per 1,000 patients [95% CI, from 78 fewer to 64 more]). Among these 6 randomized trials5–8,12,14, there was 1 randomized trial8 enrolling only patients resuscitated after in-hospital cardiac arrest due to acute coronary syndrome (N=60) showing no difference with the early insertion of intra-aortic balloon pump compared to standard care (OR 0.87 [95% CI, 0.31-2.44]).
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For the critical outcome of survival at 6 or 12 months, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 10 randomized trials enrolling 1733 patients with cardiogenic shock (59% [95% CI, 39-77] were resuscitated from cardiac arrest)1,2,4–7,10–12,14 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 1.18 [95% CI, 0.95–1.46], or 41 more survivors per 1,000 patients [95% CI, from 13 fewer to 94 more]). We identified or obtained data of the subgroup of patients with cardiac arrest from 10 randomized trials enrolling 757 patients resuscitated after cardiac arrest2–7,10,11,14 and found no difference between treatment with a mechanical circulatory support device and standard care (OR 1.21 [95% CI, 0.87–1.68], or 48 more survivors per 1,000 patients [95% CI, from 34 fewer to 129 more]). Among these, there was one randomized trial comparing a microaxial flow pump with standard care alone in infarct-related cardiogenic shock enrolling patients resuscitated from cardiac arrest but who were conscious (Glasgow Coma Scale score > 8) at hospital arrival (20% of randomized patients) which found improved survival at 6 months (OR 1.67 [95% CI 1.10–2.54)14. An individual patient data meta-analysis of 9 randomized trials comparing treatment with a mechanical circulatory support device (excluding intra-aortic ballon pump) and standard care showed no difference in the subgroup of patients with cardiac arrest (OR 1.16 [95% CI 0.83–1.63]) and a benefit only in the subgroup of patients with ST-elevation myocardial infarction without resuscitation or with resuscitation < 10 minutes (OR 1.56 [95% CI 1.13–2.16])15.
For the critical outcome of survival at the longest follow-up available, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 14 randomized trials enrolling 1875 patients with cardiogenic shock (64% [95% CI, 45-80] were resuscitated from cardiac arrest)1–13,16 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 1.17 [95% CI, 0.97–1.42], 39 more survivors per 1,000 patients [95% CI, from 7 fewer to 87 more]). We identified or obtained data of the subgroup of patients with cardiac arrest from 11 randomized trials enrolling 816 patients resuscitated after cardiac arrest2–8,10,11,14 and found no difference between treatment with a mechanical circulatory support device and standard care (OR 1.21 [95% CI, 0.91–1.60], 41 more survivors per 1,000 patients [95% CI, from 13 fewer to 94 more]). Among these 11 randomized trials, there was 1 randomized trial enrolling only patients resuscitated after in-hospital cardiac arrest due to acute coronary syndrome (N=60) showing no difference with the early insertion of intra-aortic balloon pump compared to standard care in survival at hospital discharge (OR 0.87 [95% CI, 0.31-2.44]).8 Another randomized trial comparing a microaxial flow pump with standard care alone in infarct-related cardiogenic shock enrolling also patients resuscitated from cardiac arrest but who were conscious (Glasgow Coma Scale score > 8) at hospital arrival (20% of randomized patients) found improved survival at 6 months (OR 1.67 [95% CI 1.10–2.54])14. An individual patient data meta-analysis of 9 randomized trials comparing treatment with a mechanical circulatory support device (excluding intra-aortic ballon pump) and standard care showed no difference in the subgroup of patients with cardiac arrest (OR 1.16 [95% CI 0.83–1.63]) and a benefit only in the subgroup of patients with ST-elevation myocardial infarction without resuscitation or with resuscitation < 10 minutes (OR 1.56 [95% CI 1.13–2.16])15.
For the critical outcome of survival with favourable neurological outcome at hospital discharge or 30 days, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 3 randomized trials enrolling 560 patients with cardiogenic shock (54% [95% CI, 11-92] were resuscitated from cardiac arrest)4,11,12 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 0.85 [95% CI, 0.60–1.21], or 37 fewer survivors with favourable neurological outcome per 1,000 patients [95% CI, from 109 fewer to 45 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the critical outcome of survival with favourable neurological outcome at 6 months or 1 year, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 2 randomized trials enrolling 534 patients with cardiogenic shock (41% [95% CI, 2.8-94] were resuscitated from cardiac arrest)11,12 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 1.09 [95% CI, 0.77–1.54], or 21 more survivors with favourable neurological outcome per 1,000 patients [95% CI, from 60 fewer to 106 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the critical outcome of survival with favourable neurological outcome at the longest follow-up available, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 3 randomized trials enrolling 560 patients with cardiogenic shock (54% [95% CI, 11-92] were resuscitated from cardiac arrest)4,11,12 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 1.11 [95% CI, 0.79–1.57], or 25 more survivors with favourable neurological outcome per 1,000 patients [95% CI, from 54 fewer to 111 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of moderate or severe bleeding at 30 days, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 12 randomized trials enrolling 1,738 patients with cardiogenic shock (59% [95% CI, 39-77] were resuscitated from cardiac arrest)1–7,9–13 showing higher occurrence in patients receiving a mechanical circulatory support device compared to standard care (OR 2.43 [95% CI, 1.47–4.02], or 164 more per 1,000 patients [95% CI, from 62 more to 284 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of stroke at 30 days, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 8 randomized trials enrolling 1,626 patients with cardiogenic shock (53% [95% CI, 31-74] were resuscitated from cardiac arrest)1,5,6,10–13 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 1.27 [95% CI, 0.66–2.45], or 6 more per 1,000 patients [95% CI, from 7 fewer to 30 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of haemolysis at 30 days, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 3 randomized trials enrolling 403 patients with cardiogenic shock (62% [95% CI, 3.8-99] were resuscitated from cardiac arrest)1,5,6,10–13 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 5.40 [95% CI, 0.63–46.0], or 39 more per 1,000 patients [95% CI, from 3 fewer to 93 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of peripheral ischaemic vascular complication at 30 days, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 11 randomized trials enrolling 1,710 patients with cardiogenic shock (59% [95% CI, 39-77] were resuscitated from cardiac arrest)1–3,5–7,9–13 showing higher occurrence in patients receiving a mechanical circulatory support device compared to standard care (OR 2.57 [95% CI, 1.60–4.11], or 41 more per 1,000 patients [95% CI, from 16 more to 79 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of sepsis at 30 days, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 8 randomized trials enrolling 1,565 patients with cardiogenic shock (39% [95% CI, 18-64] were resuscitated from cardiac arrest)3,5,9–13 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 1.13 [95% CI, 0.71–1.79], or 17 more per 1,000 patients [95% CI, from 40 fewer to 93 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of need of renal replacement therapy at 30 days, we have identified low-certainty evidence (downgraded for indirectness and imprecision) from 8 randomized trials enrolling 1,592 patients with cardiogenic shock (53% [95% CI, 33-72] were resuscitated from cardiac arrest)2,4–6,10–13 showing no difference between treatment with a mechanical circulatory support device and standard care (OR 1.24 [95% CI, 0.80–1.92], or 34 more per 1,000 patients [95% CI, from 31 fewer to 118 more]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of length of stay in intensive care unit, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 4 randomized trials enrolling 811 patients with cardiogenic shock (61% [95% CI, 32-84] were resuscitated from cardiac arrest)5,6,12,13 showing no difference between treatment with a mechanical circulatory support device and standard care (mean difference [MD] 1.5 days [95% CI, -0.3–3.2], 1.5 days higher [95% CI, 6.6 higher to 9.8 higher]) but an increase in ICU length of stay in studies using an active mechanical circulatory support device (i.e., extracorporeal membrane oxygenation or a left ventricular assist device) (MD 2.4 days [95% CI, 0.7–4.0]). We did not identify randomized trials reporting this outcome in cardiac arrest patients only.
For the important outcome of length of stay in hospital, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 4 randomized trials enrolling 811 patients with cardiogenic shock (61% [95% CI, 32-84] were resuscitated from cardiac arrest)6,8,12,13 showing no difference between treatment with a mechanical circulatory support device and standard care (MD 2.4 days [95% CI, -0.3–4.9], 2.4 days higher [95% CI, 0.28 lower to 4.98 higher]). Among these, there was 1 randomized trial enrolling only patients resuscitated after in-hospital cardiac arrest due to acute coronary syndrome (N=60) showing no difference (14 [IQR 2-45] days in MCS group vs. 14 [IQR 5-29] in standard care group, P=0.73).8
For the important outcome of quality of life at 1 year, we identified low-certainty evidence (downgraded for indirectness and imprecision) from 3 randomized trials enrolling 1052 patients with cardiogenic shock showing no difference between treatment with a mechanical circulatory support device and standard care in the overall quality of life among survivors10,17,18. However, in one trial patients who had undergone extracorporeal membrane oxygenation reported a higher rate of pain or discomfort17.
Treatment Recommendations
- We suggest against the routine use of mechanical circulatory support devices in patients with cardiogenic shock after cardiac arrest and return of spontaneous circulation (weak recommendation, low certainty of evidence).
- We suggest considering mechanical circulatory support devices in highly selected patients with cardiogenic shock after cardiac arrest and return of spontaneous circulation, in settings where this can be implemented (weak recommendation, low certainty of evidence).
- When a mechanical circulatory support device is used, we suggest monitoring for adverse events and complications to allow their rapid identification and treatment (good practice statement).
Justification and Evidence to Decision Framework Highlights
In making a weak recommendation against the routine use of mechanical circulatory support devices in patients with cardiogenic shock after cardiac arrest and return of spontaneous circulation, the task force considered pooled analyses from up to 14 randomized trials showing no difference in survival at various follow-ups (30 days or hospital discharge, 6 months, 1 year, and the longest available) between early routine treatment with a temporary mechanical circulatory support device and standard care in patients with cardiogenic shock, with or without prior cardiac arrest. No randomized trials were specifically designed and powered to assess a benefit in term of critical outcomes (e.g., survival or survival with favorable neurological outcome) in a population of patients with return of spontaneous circulation after cardiac arrest. All the evidence was indirect, coming from randomized trials in patients with cardiogenic shock (64% [95% CI, 45–80] of patients included were resuscitated from cardiac arrest), except a small (N=60) randomized trial enrolling only patients resuscitated from in-hospital cardiac arrest due to acute coronary syndrome8.
Although overall evidence did not support routine use of mechanical circulatory support devices, there may be certain patients who may benefit, and the task force discussed whether a selected approach to mechanical circulatory support devices in patients with cardiogenic shock after cardiac arrest and return of spontaneous circulation may be considered rather than an unselected approach and made a weak recommendation suggesting the use of mechanical circulatory support devices in highly selected patients. In making this recommendation, the task force considered:
- the results of a randomized trial comparing a microaxial flow pump with standard care alone in infarct-related cardiogenic shock which found improved survival at 180 days (hazard ratio, 0.74; 95% confidence interval, 0.55 to 0.99)14 and the fact that, in this trial, patients resuscitated from cardiac arrest who remained comatose (Glasgow Coma Scale ≤ 8) at hospital arrival were excluded, leaving a 20% of conscious patients resuscitated from cardiac arrest14. Most other trials involving patients with acute myocardial infarction and cardiogenic shock, the prevalence of patients resuscitated from cardiac arrest was high (up to 95% in one trial) and not limited to conscious patients.
- An individual patient data meta-analysis of 9 randomized trials that found a benefit of mechanical circulatory support devices in patients with ST-elevation myocardial infarction without resuscitation before arrival of the emergency medical service or short duration of resuscitation (<10 minutes) but not in the overall population of cardiac arrest patients15.
The task force discussed the lack of evidence on how to select patients with cardiogenic shock after cardiac arrest and return of spontaneous circulation for mechanical circulatory support. Based on the low certainty of evidence from randomized trials and subgroup analyses, the subgroups of patients who may potentially benefit include those with a Glasgow Coma Scale ≤ 8 at hospital arrival, patients with ST-elevation myocardial infarction without prior resuscitation before the arrival of emergency medical services, or those with a short duration of cardiac arrest (<10 minutes). The discussion mentioned also that the cause of death differs in patients with cardiogenic shock, depending on whether they experienced prior cardiac arrest. Hypoxic brain injury is the leading cause of death in those with cardiac arrest, while persistent cardiac failure is the primary cause in those without cardiac arrest. Therefore, in patients at high risk of brain injury, which cannot be addressed by mechanical circulatory support devices, the benefit of these devices may be less apparent. In the CoSTR on predicting good neurological outcomes after cardiac arrest19, the task force found one study that showed a Glasgow Coma Scale motor score of 4–5 assessed at intensive care unit admission predicted favorable outcomes at 3 months, with a specificity of 98% (95% CI 93–99%) and sensitivity of 12% (95% CI 7–17%)20. Other predictors of good neurological outcomes, though not available at admission, included normal neuron-specific enolase blood values at 24–72 hours, an somatosensory evoked potential N20 wave amplitude above 4 μV, a continuous electroencephalogram background without discharges within 72 hours, or the absence of diffusion restriction in the cortex or deep grey matter on magnetic resonance imaging between days 2–7.21–24 The task force agreed that, based on the current level of available evidence, making clear recommendations on how to select patients with cardiogenic shock after cardiac arrest and return of spontaneous circulation for mechanical circulatory support is challenging. There was also a discussion about the risk of prematurely ruling out interventions for patients with possible neurological recovery based solely on early coma, as done in one trial13.
In making these recommendations, the task force also considered:
- that implementation of mechanical circulatory support may incur significant costs and require specialized resources and skills, which may not be available or feasible in all settings;
- the 2023 European Society of Cardiology (ESC) Guidelines for the management of acute coronary syndromes stating that in patients with acute coronary syndrome and severe/refractory cardiogenic shock, short-term mechanical circulatory support may be considered (class of recommendation IIb, level of evidence C) and that the routine use of an intra-aortic balloon pump in patients without mechanical complications is not recommended (class of recommendation III, level of evidence B) and the 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support stating that acute mechanical circulatory support should be initiated as soon as possible in patients with cardiogenic shock who fail to stabilize or continue to deteriorate despite initial interventions25.
Finally, while mechanical circulatory support devices may be considered for highly selected patients, the task force emphasized the need for caution until further evidence becomes available. Given the increased rates of complications—particularly bleeding and limb ischemia—in patients with infarct-related cardiogenic shock treated with mechanical circulatory support devices, especially when venoarterial extracorporeal membrane oxygenation or left ventricular assist devices are used, the task force found it reasonable to issue a good practice statement recommending close monitoring for adverse events and complications if mechanical circulatory support is employed.
Knowledge Gaps
- No studies were identified that evaluated the effect of mechanical circulatory support devices on neurologically intact survival in patients with cardiac arrest.
- Subpopulation of post-cardiac arrest patient in cardiogenic shock that might benefit from mechanical circulatory support
- The value of mechanical circulatory support devices in patients without acute myocardial infarction-related cardiogenic shock or post-resuscitation shock following cardiac arrest of non-cardiac origin
- The comparative effectiveness of different mechanical circulatory support devices or combinations of devices (e.g., ECPELLA, BIPELLA)
- The optimal timing for initiating mechanical circulatory support after the return of spontaneous circulation
- The ideal settings for implementing mechanical circulatory support in post-cardiac arrest patients
- The cost-effectiveness of mechanical circulatory support in post-cardiac arrest patients
ETD summary table: ALS 3505 Et D MCS post ROSC
References
References listed alphabetically by first author last name in this citation format (Circulation)
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