Defining cost-effectiveness of mechanical circulatory support escalation among patients with acute myocardial infarction complicated by cardiogenic shock
- 1The Royal Melbourne Hospital
Abstract
BackgroundTemporary 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.
MethodsWe 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.
ResultsExpected 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.
ConclusionsUnder 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.
What Is Known* Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) carries high short-term mortality and substantial healthcare costs. Temporary mechanical circulatory support (MCS) strategies differ markedly in clinical effectiveness, complication profiles, acquisition costs, and critical-care resource use.
* Existing economic evaluations have largely been limited to pairwise comparisons and have not assessed escalation from No MCS to multiple MCS strategies within a single cost-effectiveness framework in a public, government-funded healthcare setting.
What the Study Adds* A common cost-effectiveness frontier comparing No MCS with mFP, VA-ECMO, and mFP-ECMO showed that mFP was the only non-dominated MCS strategy, with an incremental cost-effectiveness ratio of A$502,695 per additional 30-day survivor.
* VA-ECMO and mFP-ECMO would each require 30-day survival exceeding 74.2% to avoid economic dominance. VA-ECMO remained dominated even when its device acquisition cost was reduced to zero.
* ICU bed-days, rather than device acquisition alone, were the principal cost driver in every arm, identifying critical-care resource use as the factor with the greatest influence on value.
Related
- Comparative efficacy and safety of mechanical circulatory support in ST-elevation myocardial infarction with cardiogenic shock: a network meta-analysis
- Temporary Mechanical Circulatory Support in Acute Myocardial Infarction-Related Cardiogenic Shock: Lessons from Contemporary Randomized Trials
- Sex Differences in Vasopressor De-escalation With Arginine Vasopressin in Mixed Cardiogenic-Vasodilatory Shock Under VA-ECMO
- Loeffler endocarditis complicated by cardiogenic shock and angioinvasive Fusarium fujikuroi infection: a case report.
- Acute Anterior ST-Elevation Myocardial Infarction With Right Bundle Branch Block Complicated by Complete Atrioventricular Block and Cardiogenic Shock in a 21-Year-Old Man: A Case Report
BibTeX
@misc{kamalakkannan2026defining,
title = {{Defining cost-effectiveness of mechanical circulatory support escalation among patients with acute myocardial infarction complicated by cardiogenic shock}},
author = {A. Kamalakkannan and Y. Yang and R. Batchelor and B. Backhouse and K. Munro and F. Groen and F. Yanase and J. Anstey and A. Taylor and J. Dyett and C. French and F. McGain and J. Lefkovits and N. Cox and W. Chan},
howpublished = {medRxiv},
year = {2026},
month = sep,
doi = {10.64898/2026.09.08.26362578},
url = {https://www.medrxiv.org/content/10.64898/2026.09.08.26362578v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - Defining cost-effectiveness of mechanical circulatory support escalation among patients with acute myocardial infarction complicated by cardiogenic shock
AU - A. Kamalakkannan
AU - Y. Yang
AU - R. Batchelor
AU - B. Backhouse
AU - K. Munro
AU - F. Groen
AU - F. Yanase
AU - J. Anstey
AU - A. Taylor
AU - J. Dyett
AU - C. French
AU - F. McGain
AU - J. Lefkovits
AU - N. Cox
AU - W. Chan
PY - 2026
DA - 2026/09/08
PB - medRxiv
DO - 10.64898/2026.09.08.26362578
UR - https://www.medrxiv.org/content/10.64898/2026.09.08.26362578v1
AB - BackgroundTemporary 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. MethodsWe 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. ResultsExpected 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. ConclusionsUnder 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. What Is Known* Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) carries high short-term mortality and substantial healthcare costs. Temporary mechanical circulatory support (MCS) strategies differ markedly in clinical effectiveness, complication profiles, acquisition costs, and critical-care resource use. * Existing economic evaluations have largely been limited to pairwise comparisons and have not assessed escalation from No MCS to multiple MCS strategies within a single cost-effectiveness framework in a public, government-funded healthcare setting. What the Study Adds* A common cost-effectiveness frontier comparing No MCS with mFP, VA-ECMO, and mFP-ECMO showed that mFP was the only non-dominated MCS strategy, with an incremental cost-effectiveness ratio of A$502,695 per additional 30-day survivor. * VA-ECMO and mFP-ECMO would each require 30-day survival exceeding 74.2% to avoid economic dominance. VA-ECMO remained dominated even when its device acquisition cost was reduced to zero. * ICU bed-days, rather than device acquisition alone, were the principal cost driver in every arm, identifying critical-care resource use as the factor with the greatest influence on value.
ER -