A 30-day decision-analytic model comparing four mechanical circulatory support (MCS) strategies in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) found that microaxial-flow pumps (mFP) were the only cost-effective escalation option. Per-patient costs reached A$34,562 for standard care, A$125,269 for mFP, A$133,573 for VA-ECMO, and A$177,481 for combined mFP-ECMO. Crucially, modelled 30-day survival favored mFP at 74.2% versus 56.1% for no MCS, while VA-ECMO (54.3%) and mFP-ECMO (53.9%) failed to outperform standard care — making them strictly dominated strategies. The incremental cost-effectiveness ratio for mFP versus no MCS was A$502,695 per additional survivor, with ICU bed-days identified as the largest cost driver.
This preprint — not yet peer-reviewed — arrives amid intense clinical debate following trials like ECMO-CS and EURO SHOCK, which have questioned routine VA-ECMO use in AMI-CS. The modelling aligns with that skeptical trajectory, but carries significant caveats: survival inputs were drawn from heterogeneous cross-cohort sources rather than a single randomized trial, a methodological vulnerability that the authors themselves acknowledge through scenario analyses. Decision models are inherently sensitive to input assumptions, and the survival estimates for VA-ECMO and mFP-ECMO appear notably pessimistic compared to some registries. Real-world patient selection also matters enormously — the authors appropriately note that escalated support remains clinically necessary for patients with refractory shock or combined cardiorespiratory failure. For health systems and procurement decisions, this analysis offers a useful economic framework, but clinicians should await peer review before revising escalation protocols.