Defining cost-effectiveness of mechanical circulatory support escalation among patients with acute myocardial infarction complicated by cardiogenic shock.

Abstract

Background: Temporary mechanical circulatory support (MCS) for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) includes microaxial-flow pumps (mFP), venoarterial extracorporeal membrane oxygenation (VA-ECMO), and combined mFP-ECMO support. These strategies differ substantially in haemodynamic capability and resource use, but their short-term cost-effectiveness has not been compared within a common decision framework. Method(s): We developed a 4-strategy decision-analytic model comparing No MCS (standard care without temporary MCS), mFP, VA-ECMO, and mFP-ECMO from the perspective of a publicly funded Australian health system over 30 days. Costs were estimated from individual resource components in 2025-26 Australian dollars and benchmarked against hospital casemix data. The primary outcome was cost per additional 30-day survivor. Scenario analyses and probabilistic sensitivity analysis assessed parameter uncertainty. Result(s): Expected per-patient costs were A$34,562 for No MCS, A$125,269 for mFP, A$133,573 for VA-ECMO, and A$177,481 for mFP-ECMO. Assigned 30-day survival probabilities were 56.1%, 74.2%, 54.3%, and 53.9%, respectively. mFP was the only non-dominated MCS strategy, with an incremental cost-effectiveness ratio of A$502,695 per additional survivor compared with No MCS. Under the assigned cross-cohort inputs, VA-ECMO and mFP-ECMO were more costly and less effective, remained strictly dominated across all prespecified scenarios, and required 30-day survival above 74.2% to escape dominance. Intensive care unit (ICU) bed-days were the largest cost component. At a willingness-to-pay threshold of A$500,000 per additional survivor, the probabilities of being optimal were 44.0% for No MCS, 54.1% for mFP, 1.7% for VA-ECMO, and 0.2% for mFP-ECMO. Conclusion(s): Under the assigned cross-cohort inputs, escalation of MCS beyond mFP in AMI-CS increased costs without improving modelled 30-day survival. Nevertheless, VA-ECMO and mFP-ECMO remain essential for selected patients requiring greater circulatory or respiratory support.Copyright © 2026, Posted by openRxiv