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Introduction: Recent reports have demonstrated an association between Impella compared to IABP use with increased risk for short-term clinical outcomes, including stroke, bleeding, and mortality among patients with AMI and cardiogenic shock (CS) undergoing PCI. Data on long-term outcomes and cost are limited. Methods: This retrospective study analyzed administrative claims data from a large commercially insured population from 14 states. Patients undergoing PCI for AMI complicated by CS from 7/1/14 to 4/30/20 were included. Those who had both devices or other mechanical circulatory support were excluded. We performed a 1:1 propensity score-matched analysis in patients receiving an Impella versus IABP. The primary outcome was mortality, and secondary outcomes were stroke, bleeding, repeat revascularization, incident dialysis, and cost at 30-days and 1-year follow-up. Results: Of the 3,347 patients undergoing PCI for AMI complicated by CS, the mean (SD) age was 65.4 (12.5) years, 71% were men, and 32% had a cardiac arrest. Among 820 propensity-matched pairs, at 30-days use of the Impella was associated with a significantly higher mortality (Odds ratio [OR] 1.91; 95% Confidence interval [CI]: 1.54-2.37, P P =0.01), and mean difference in cost ($40,869, Interquartile range: $20,829-$64,200, P Figure ). Incident stroke, bleeding, and repeat revascularization were not different between groups ( P >0.05). At 1-year, mortality (Hazard ratio [HR] 1.58, 95% CI: 1.33-1.87, P P =0.001) remained higher in Impella. Conclusions: In patients undergoing PCI for AMI complicated by CS, use of Impella was associated with an increased 30-day and 1-year mortality, dialysis, and cost compared to IABP. There is need for additional evidence surrounding the optimal management of patients with AMI and CS undergoing PCI.

Intravascular microaxial left ventricular assist device (LVAD) compared with intra-aortic balloon pump (IABP) has been associated with increased risk of mortality and bleeding among patients with acute myocardial infarction (AMI) and cardiogenic shock (CS) undergoing percutaneous coronary intervention (PCI). However, evidence on the association of device therapy with a broader array of clinical outcomes, including data on long-term outcomes and cost, is limited.To examine the association between intravascular LVAD or IABP use and clinical outcomes and cost in patients with AMI complicated by CS.This retrospective propensity-matched cohort study used administrative claims data for commercially insured patients from 14 states across the US. Patients included in the analysis underwent PCI for AMI complicated by CS from January 1, 2015, to April 30, 2020. Data analysis was performed from April to November 2021.Use of either an intravascular LVAD or IABP.The primary outcomes were mortality, stroke, severe bleeding, repeat revascularization, kidney replacement therapy (KRT), and total health care costs during the index admission. Clinical outcomes and cost were also assessed at 30 days and 1 year.Among 3077 patients undergoing PCI for AMI complicated by CS, the mean (SD) age was 65.2 (12.5) years, and 986 (32.0%) had cardiac arrest. Among 817 propensity-matched pairs, intravascular LVAD use was associated with significantly higher in-hospital (36.2% vs 25.8%; odds ratio [OR], 1.63; 95% CI, 1.32-2.02), 30-day (40.1% vs 28.3%; OR, 1.71; 95% CI, 1.37-2.13), and 1-year mortality (58.9% vs 45.0%; hazard ratio [HR], 1.44; 95% CI, 1.21-1.71) compared with IABP. At 30 days, intravascular LVAD use was associated with significantly higher bleeding (19.1% vs 14.5%; OR, 1.35; 95% CI, 1.04-1.76), KRT (12.2% vs 7.0%; OR, 1.88; 95% CI, 1.30-2.73), and mean cost (+$51 680; 95% CI, $31 488-$75 178). At 1 year, the association of intravascular LVAD use with bleeding (29.7% vs 24.3%; HR, 1.36; 95% CI, 1.05-1.75), KRT (18.1% vs 10.9%; HR, 1.95; 95% CI, 1.35-2.83), and mean cost (+$46 609; 95% CI, $22 126-$75 461) persisted.In this propensity-matched analysis of patients undergoing PCI for AMI complicated by CS, intravascular LVAD use was associated with increased short-term and 1-year risk of mortality, bleeding, KRT, and cost compared with IABP. There is an urgent need for additional evidence surrounding the optimal management of patients with AMI complicated by CS.