**9. Conclusion**

In female patients or in patients with a BSA less than 1.7 m2

56.8% have been reported [37, 55, 56].

286 Principles and Practice of Cardiothoracic Surgery

prove the current techniques and devices.

**8. Future implications**

peripheral vascular disease, the distal catheter is inserted as soon as possible.

Patients with acute coronary syndrome complicated by advanced cardiogenic shock had a higher survival than patients presented with cardiac arrest. Kim et al. [45] reported an early survival of 59.2% in a group of 27 patients and described a long-term survival of 42.9% at 3 years. Bermudez et al. [39] described an early survival of 64% in a group of 33 patients affected by AMI and advanced CS. The 2-year survival was 48%. Sakamoto et al. [38] reported a cumulative early survival of 32.7% in a group of 98 patients affected by refractory CS following AMI in which 36.7% had CA on arrival. Other early survival rate ranging between 33.3% and

Recently, some Authors have reported early results about the use of IABP in the setting of cardiogenic shock following acute myocardial infarction and in these articles the IABP seems to have not robust data to be still considered as the tool of first choice in the treatment of cardiogenic shock. Seyfart et al [57], in a randomized study of 25 patients with CS, randomly assigned to IABP (n=13) and percutaneous Impella 2.5 (n=12), reported a superior hemodi‐ namic parameter and a significative increasing of cardiac index in patients treated with Impella; the 30 days mortality (46%) was not different in both groups. In a meta-analisys published by Sjauw et al. [58] about the use of IABP in the setting of ST-elevation myocardial infarction complicated by cardiogenic shock, the Authors could not find robust data in favours of the use of IABP. Different complications such as stroke and bleeding and increasing of 30 days mortality in patients managed with IABP were observed. A very recent article by Thiele and al [59], 600 patients affected by CS following acute myocardial infarction, were randomly assigned to IABP therapy (n = 300) or conventional therapy (n = 298). The Authors could not find significant differences in 30-days mortality and in secondary end points or in process-ofcare measures, including the time to hemodynamic stabilization, the length of stay in the intensive care unit. No other significant differences with respect to the rates of major bleeding, peripheral ischemic complications and stroke were reported between the two groups. Ho‐ wewer all these results have received different criticisms due to small number of patients [57] or a high number of patients with a relatively low mortality risk if treated with conventional therapy [59] and therefore these report could be influenced from some confounding factors.

According to these recent results, in the next close future, it can be argued that the use of ECMO could be more encouraged and anticipated in such patient who are in the setting of "pre-shock", in order to reduce the complications linked to the low cardiac output and to reduce the rate of very late application of ECMO. The current systems are safe and simple to apply, due to the advance in miniaturized centrifugal pumps and circuits, to the increased biocompatibility (heparin-coated system), but they are still associated with major complications in a relatively high percentage. Big efforts are still needed to im‐

or in patients with a severe

The use of V-A ECMO in patients with acute myocardial infarction complicated by refractory cardiogenic shock and or cardiac arrest is widely increasing due to the improving in the early e mid-term results. The relatively low early survival rate in these very illness patients sup‐ ported by ECMO should be considered an encouraging data, because in these patients the mortality without the ECMO support is dramatically higher. Bleeding, infections and CNS irreversible damage remain still serious complications and efforts to reduce or prevent them are necessary and strongly recommended to improve the outcome.
