PCI Assisted By Invasive Mechanical Ventilation And IABP For Acute Myocardial Infarction With Cardiogenic Shock:Retrospective Cohort Study And Meta Analysis

Aims:The treatment of acute myocardial infarction?AMI?complicated with cardiogenic shock?CS?is mainly based on early revascularization and mechanical circulatory support devices.Mechanical ventilation is also widely used in the treatment.However,research on ventilation modes and strategies is inadequate.We aimed to investigate the clinical efficacy and prognosis of invasive mechanical ventilation?IMV?based on intra-aortic balloon pump?IABP?and PCI.Methods:1.Patients with CS complicating AMI were recruited in Tianjin Chest Hospital from January 1,2016 to June 1,2017,who were undergoing IMV?protective lung ventilation strategy with PEEP set at 5-10cmH₂O?and IABP combined with PCI.The follow-up time was 1 year.The endpoint were in-hospital,30-day,6-month and 1-year all-cause mortality.2.By retrieving literatures published in PubMed,Cochrane Library,Embase databases from January 1,1997 to December 1,2017,we conducted a meta analysis of the in-hospital mortality of AMI with CS patients received IMV.In addition,we also cited a meta analysis of IABP in the treatment of AMI with CS.3.The outcomes of retrospective cohort study were compared with results of the above-mentioned meta analysis and the existing meta analysis of AMI with CS patients underwent revascularization combined with IABP.3.COX regression analysis was used to explore risk factors for 1-year all-cause mortality in cohort study.Results:1.60 patients were eligible for study inclusion.The mean age was 67 years old,71.67%were men.Coronary angiography showed 56 cases?93.33%?with multivessel disease and 14 cases?23.33%?with left main disease.Of these 60 patients,95%underwent primary PCI and 88.3%achieved TIMI 3 flow after PCI.The primary outcome of all-cause mortality rate in-hospital,and at 30 days,6 months and 1 year was 25%?95%CI:0.14-0.36?,28.8%?95%CI:0.17-0.41?,32.2%?95%CI:0.20-0.44?and33.9%?95%CI:0.22-0.46?,respectively.2.Our meta analysis identifed 5 studies that reported the in-hospital mortality of AMI with CS received invasive mechanical ventilation.After removing one non-randomized controlled trial with greater heterogeneity,4 observational studies were eventually included.The total number of patients was 379.Due to the low heterogeneity?I²=39.7%,p=0.174?,results were combined using a fixed effect model and the pooled in-hospital mortality was 66%?95%CI:0.62-0.71?.We cited a meta analysis about IABP published on the Cochrane Database of Systematic Reviews in2015.The treatment strategy of AMI with CS was IABP combined with revascularization therapy.The in-hospital,30-day,6-month and 1-year all-cause mortality were 36%?95%CI:0.31-0.41?,40%?95%CI:0.35-0.45?,49%?95%CI:0.43-0.54?and 52%?95%CI:0.47-0.58?,respectively,which were pooled by fixed effect model.3.Compared with the meta analysis about IABP,the 1-year all-cause mortality rate of the cohort study was statistically reduced.However,the in-hospital,30-day,6-month and 1-year all-cause mortality were numerically but not significantly lower than that of meta analysis's results.In addition,there was statistically significant difference between this primary study and meta analysis about IMV.4.In COX regression analysis,lactic acid level?4.5mmol/L?HR:3.99,95%CI:1.29-12.34,p=0.0161?,hyperuricemia?HR:4.51,95%CI:1.63-12.45,p=0.0037?and TIMI flow grade<3 after PCI?HR:12.1,95%CI:3.71-39.43,p?0.0001?were independent predictors of death at 1 year.Conclusions:1.Meta-analysis showed that the in-hospital all-cause mortality rate of CS complicating AMI treated with IMV was 66%?95%CI:0.62-0.71?.2.All-cause mortality at 1 year in patients with CS complicating AMI treated with IMV and IABP assisted PCI was significantly reduced.Larger,longer-term direct comparisons are warranted.3.We found that elevated arterial lactate,hyperuricemia,and TIMI flow grade<3 after PCI were risk factors for death.