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Background Mortality from cardiogenic shock complicating acute myocardial infarction (AMI-CS) is high, despite increasing mechanical circulatory support (MCS) use in clinical practise. Recent large-scale trials have provided conflicting results about the mortality benefit of MCS in AMI-CS.Purpose To assess the safety and efficacy of temporary MCS in adults with AMI-CS, and compare different MCS devices.Methods We conducted a systematic review and meta-analysis of all randomized controlled trials assessing MCS in adults with AMI-CS. We searched Medline, EMBASE, CENTRAL, Web of Science, and Scopus from inception to May 2024. We evaluated the effect of each intervention on early (in-hospital or 30-day) mortality using a random-effects network meta-analysis of odds ratios (ORs), whilst assuming consistency between direct and indirect evidence. Safety outcomes included stroke, bleeding, and sepsis.Results Fourteen trials randomizing 1858 patients were included: Intra-aortic balloon pump (IABP) vs medical therapy (4 trials, n=748), Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) vs no VA-ECMO (4 trials, n=568), and percutaneous Ventricular Assist Device (pVAD) vs no pVAD (6 trials, n=542). No MCS device showed a significant effect on early mortality compared to initial medical therapy [IABP (OR 0.87, 95% CI 0.66 - 1.15), VA-ECMO (OR 0.91, 95% CI 0.65 - 1.27), pVAD (OR 0.88, 95% CI 0.61 - 1.20), P (inconsistency) = 0.76], ( figures 1 and 2). VA-ECMO and pVAD were associated with increased major bleeding [OR 2.81 (95% CI 1.68 – 4.71) and OR 5.13 (95% CI 1.87 – 14.04)], respectively). Higher rates of stroke and sepsis were noted with pVAD. No significant safety concerns were identified with IABP.Conclusion The early mortality benefit of MCS devices in AMI-CS remains unproven, and their use may increase risks like bleeding, stroke, and sepsis.Abstract 32 Figure 1Early mortality (odds ratio). IABP Intra-aortic balloon pump, ECMO Extra-corporeal membrane oxygenation, pVAD percutaneous ventricular assist device, CI confidence intervalAbstract 32 Figure 2Network meta-analysis. Network map (A) width of edges are proportional to the number of events in the comparison. Size of node is proportional to the number of trials that includes that intervention. Network meta-analysis forest plot (B) each device compared to initial medical therapy or alternative device with respect to effect on early mortality. IABP intra-aortic balloon pump, ECMO extra-corporeal membrane oxygenation, pVAD percutaneous ventricular assist device, CI confidence interval