**5. Conclusion**

ventricular loading and increase in afterload with VA-ECMO are being made with the combination of an unloading device such as IABP or the use of Impella® [74, 75]. Better weaning and lower in-hospital and 28-day mortality were reported with Impella® of VA-ECMO along with IABP in a propensity-matched national registry [74]. Considering the lack of RCTs, systematic reviews should be taken into account as well as two small nonrandomized registries (n = 95) comparing VA-ECMO with IABP and Impella® and two other studies (n = 140) conducted with Impella RD® and TandemHeart [54, 75]. Considering the 30-day survival rate of VA-ECMO, in this meta-analysis, it is obviously superior to IABP with 33% absolute survival rate. No benefit was observed when compared with ECLS and pMCS (Impella®, TandemHeart). In conclusion, the total meta-analysis did not indicate any significant benefits. When addressed as a whole, the meta-analysis data of VA-ECMOs/ECLS and pMCS are inconsistent: on the one hand, pMCSs are not better than IABP, whereas, on the other, VA-ECMOs/ECLS are better than IABP while they are not better than pMCSs. Of course, there is a need for higherquality RCTs to be able to answer the questions about the routine use of VA-ECMO/ECLS in treatment-resistant CS patients [44, 49]. It is seen that 75% of the survivors after ECLS are able to go about their daily life, 25% of them return to work or school, and 57% of them are not limited in their usual activities. However, when compared to a normative age-matched

Coronary revascularization probably with pPCI should be planned as soon as possible in STEMI/NSTEMI patients with impaired pump function. In the IABP-SHOCK II trial conducted with 600 patients between 2009 and 2012, emergency coronary revascularizations were performed with pPCI in 95.8% of them and with CABG in 3.5% usually after unsuccessful pPCI, and revascularization was not performed only in 3.2% of them [5]. Early coronary revascularization is the key recommendation for treatment of CSMI patients [29, 32, 33, 37, 50, 51]. The SHOCK trial conducted with 302 CSMI patients between 1993 and 1998 revealed a tendency for early revascularization compared to conservative treatment whether with pPCI (64%) or CABG (36%) in terms of 30-day mortality (56.0 vs. 47.6%; p = 0.11) [77]. However, the 6-month (49.7 vs. 36.9%; p = 0.027), 12-month (46.7 vs. 33.6%; p < 0.04), and even 6-year (32.8 vs. 19.6%; p = 0.03) survival rates, for early revascularization, are significantly high [77–79]. SMASH (Swiss Multicenter Trial of Angioplasty for SHOCK) trial, which is the second study suitable for early coronary revascularization, was prematurely terminated due to low participation after only 55 CSMI patients were included. This study seemed neutral regarding 30-day mortality [5]. The low mortality rates of CSMI patients in the data registry reports of numerous countries such as France, Italy, Switzerland, Sweden, and the United States in the past 30 years were attributed to the increased rates of pPCI [3]. The "real-world" situation in Germany is reflected by the registry data addressing 2.818 CSMI-treated patients, of whom 85% were treated with pPCI, 4.2% with CABG, and 8.9% with noninterventional treatment. Hospital mortality rates were

population, significantly lower quality-of-life indices are reported [76].

42% for pPCI, 21.7% for CABG, and 47.8% for noninterventional treatment [80].

The preferred approach is primary percutaneous coronary intervention (pPCI). The decision to carry out revascularization in CSMI patients with multivessel disease or left main coronary

**4.5. Reperfusion**

24 Advances in Extra-corporeal Perfusion Therapies

*4.5.1. Types of revascularization*

Examining the patients with CS, we can see that we have many problems to deal with and solve. Due to ever-increasing risk factors for MI, particularly due to rapidly increasing world population, aging populations, and tobacco use, the number of CS patients is increasing day by day despite the serious advances and solutions in ACS. Although pMCS devices manufactured specifically with advancing technology are considered to be good solutions, they do pose new and serious problems. They are not suitable for every country or society due to their high application and device costs and particularly due to the fact that they cannot guarantee life. We need to allocate more resources to the abovementioned problems for the sake of public health through the world, and we need to produce pMCS devices that are suitable for each population, easy to apply, inexpensive, transportable, permanent, and effective so that the patient can be transferred to a cardiac center no matter where the patient is. One clear fact revealed by this study is the lack of clarity with respect to pMCS indications due to a low number of controlled randomized clinical trials. Early and effective revascularization is the best treatment option for CS. To this end, those organizations operating on both national and global bases are going to play the most active role for the short-term and long-term survival of patients.
