Background

Acute myocardial infarction-related cardiogenic shock (AMI-CS) remains associated with extremely high mortality in patients with acute myocardial infarction despite timely revascularization and advances in mechanical circulatory support (MCS). Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used as rescue therapy during percutaneous coronary intervention (PCI); however, ECMO-related left ventricular overload may compromise myocardial recovery. Whether concomitant intra-aortic balloon pump (IABP) support improves outcomes in this setting remains uncertain.

Methods

We conducted a single-center retrospective cohort study including adult patients with cardiogenic shock undergoing PCI supported with V-A ECMO between January 2020 and December 2025. Patients were stratified according to the use of adjunctive IABP (ECMO-IABP vs. ECMO alone). Propensity score matching (1:1) was performed using age, sex, lactate and VIS before ECMO. The primary endpoint was in-hospital mortality. Secondary outcomes included ECMO weaning success, complications, length of intensive care unit stay and 30-day survival. Survival was assessed using Kaplan–Meier analysis.

Results

Among 57 eligible patients, 22 received concomitant IABP support and 35 were treated with V-A ECMO alone. After propensity score matching, 44 patients were included in the final analysis. Successful weaning from V-A ECMO was significantly more frequent in the ECMO-IABP group compared with ECMO alone (86.4% vs. 59.1%, p = 0.027). No statistically significant difference in in-hospital mortality was observed between the groups. In the unmatched cohort, 30-day survival was significantly higher in patients treated with concomitant IABP support (log-rank p = 0.038); after propensity score matching, no significant survival difference was observed (log-rank p = 0.051). Rates of major bleeding (BARC ≥ 3), vascular complications, renal failure, and neurological events were comparable between groups.

Conclusions

In patients with AMI-CS undergoing PCI supported with veno-arterial ECMO, adjunctive intra-aortic balloon pump support was associated with a higher rate of successful ECMO weaning. No significant difference in in-hospital mortality was observed after propensity score matching. A non-significant trend toward improved short-term survival was noted.