Integrating bibliometric analysis and external validation of the SAVE score in VA-ECMO for refractory cardiogenic shock: insights from global trends and the MIMIC-IV database.

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a crucial intervention for patients with refractory cardiogenic shock, though its management is complex and carries substantial risks such as thromboembolism, hemorrhage, and infection. This study aims to provide a comprehensive overview of global research trends and to assess the clinical utility of established prognostic tools.

METHODS

A literature search was conducted on the Web of Science Core Collection from 1988 to 2024. The bibliometric tools VOSviewer 1.6.20, CiteSpace 6.3.R1, and the R 4.3.3 were employed to visualize collaboration networks, keyword co-occurrences, and emerging research trends. Additionally, a retrospective cohort of adult patients with refractory cardiogenic shock who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was identified from the Medical Information Mart for Intensive Care IV (MIMIC-IV) (v2.2) database. The Survival After Veno-Arterial ECMO (SAVE) score's discrimination and calibration were externally validated in this cohort.

RESULTS

The bibliometric analysis showed that the USA led in publications [129], followed by France [96] and China [72], with Assistance Publique Hôpitaux Paris (APHP) and Institut National de la Santé et de la Recherche Médicale (INSERM) among key institutions. Major journals included ASAIO Journal, Perfusion-UK, and Artificial Organs, and leading authors were Alain Combes, Pascal Leprince, and Guillaume Lebreton. Since 2020, research hotspots have shifted toward "ventricular assist device", "guidelines", and "hospital cardiac arrest". In the MIMIC-IV validation cohort (n=101), the SAVE score demonstrated limited discrimination [area under the receiver operating characteristic curve (AUC-ROC) 0.578] and significant miscalibration for predicting in-hospital mortality among VA-ECMO patients. Decision curve analysis indicated minimal net clinical benefit, underscoring the importance of external validation and model adaptation for real-world practice.

CONCLUSIONS

This study underscores the performance variations of established prognostic tools across different clinical settings, suggesting that tools like the SAVE score require cautious interpretation when applied to localized cohorts. Future ECMO research in cardiogenic shock must refine management strategies, standardize guidelines, and improve prediction models through rigorous multi-center external validation. Leveraging large clinical databases such as MIMIC-IV will be essential for advancing precision medicine and optimizing outcomes in this high-risk population.