Cardiogenic shock in patients with papillary muscle rupture post-acute myocardial infarction: a systematic review and meta-analysis

Backgroud

Although emergency mitral valve surgery (MVS) is the preferred treatment for papillary muscle rupture (PMR) post-acute myocardial infarction (AMI), cardiogenic shock (CS) patients may be denied, due to high surgical risk. These patients may benefit from mitral transcatheter edge-to-edge repair (M-TEER) as a bridge therapy or permanent solution.

Purpose

We aimed to perform a systematic review and meta-analysis of the literature regarding therapeutic options for PMR post-AMI patients complicated with CS.

Methods

We searched PubMed, Web of Science, and SCOPUS from January 1990 to February 2026. Studies reporting CS in patients with PMR post-AMI and mortality as a primary outcome have been included. The secondary outcomes were use of mechanical circulatory support (MCS) and associated mortality. Single-arm meta-analysis of proportions was performed in R (v. 4.5.2) using a random-effects model with Hartung–Knapp adjustment, given the absence of direct comparative studies between MVS and M-TEER. Outcomes were reported with 95% confidence interval (CI). Heterogeneity was assessed using the I² statistic.

Results

A total of 10 observational studies were analyzed: three M-TEER articles, five MVS articles, one extra-corporeal life support (ECLS) article, and one article which included patients with and without interventions. The latter was not included in the meta-analysis of proportions, as it didn’t report separate data for CS patients who underwent interventions as opposed to those without interventions. The remaining nine studies, with 933 adult patients, were included in this meta-analysis.

Across seven studies with PMR post-AMI and CS (n=875), the pooled in-hospital mortality was 31% (95% CI: 28–35%), with moderate heterogeneity (I² = 43%). In subgroup analyses, pooled in-hospital mortality was: 31% (95% CI: 26–36%; I² = 54%) in the MVS cohort (n=839), respectively 42% (95% CI: 27–58%; I² = 29%) in the M-TEER cohort (n=36). Four studies reporting 1-year outcomes (n=87) demonstrated a pooled 1-year mortality of 29% (95% CI: 16–46%), with moderate-to-low heterogeneity (I² = 27%).

The pooled proportion of patients requiring MCS (n=173) was 90% (95% CI: 65–98%), indicating a high need for hemodynamic support in this population. Among patients requiring MCS (n=100), pooled mortality was 50% (95% CI: 34–66%; I² = 41%), highlighting the severe prognosis once advanced support is needed. All these findings represent indirect comparisons across non-randomized cohorts and should be interpreted cautiously.

Conclusion

PMR after AMI complicated by CS is associated with high mortality and frequent use of MCS. Although MVS showed numerically lower mortality than M-TEER, the available evidence is limited and non-comparative. Overall outcomes remain poor despite contemporary management, highlighting the severity of the condition and the need for further studies directly comparing surgical and transcatheter strategies.Procedural (MVS or M-TEER) mortalitiesMCS use & mortality