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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/16\\\/4\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/16\\\/4\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/16\\\/4\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/16\\\/4\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003ECardiogenic shock accounts for about one half of the in-hospital mortality after an acute myocardial infarction. Rapid diagnosis and mechanical reperfusion can improve survival. Mechanical support is an important tool to manage but profound shock or cardiovascular collapse. Extracorporeal life support and other technologies are promising but additional evidence is needed to determine their impact on mortality.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiogenic shock\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eacute myocardial infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eintra-aortic balloon pump\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESHOCK\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIABP-SHOCK II\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eextracorporeal life support\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epercutaneous coronary intervention\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eimpella\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETandemHeart\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eextracorporeal membrane oxygenation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine clinical trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EWith an incidence between 5% and 10% and an in-hospital mortality rate of about 50%, cardiogenic shock (CS) is the leading cause of death among patients hospitalized for acute myocardial infarction (AMI) [Kolte D et al. \u003Cem\u003EJ Am Heart Assoc.\u003C\/em\u003E 2014; Hochman JS. \u003Cem\u003ECirculation.\u003C\/em\u003E 2003]. Khaled M. Ziada, MD, Gill Heart Institute, University of Kentucky, Lexington, Kentucky, USA, discussed trends in the treatment of this dangerous condition.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EAccording to Dr Ziada, the primary objectives for the management of CS are to support brain and kidney function; prevent or reverse acidosis; and reverse vasodilation, hypoxemia, and systemic hypoperfusion as quickly as possible. The use of mechanical hemodynamic (HD) support (eg, intra-aortic balloon pump [IABP]) is broadly accepted as a necessary intervention despite the paucity of randomized trial data. Registry data indicate that IABP improves the cardiac index and coronary perfusion while reducing afterload and left ventricular end-diastolic pressure. However, IABP is a temporary measure that does not decrease mortality.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe majority (86%) of subjects in both arms of the SHOCK trial [Hochman JS et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2006] received IABP support. Although emergency revascularization did not significantly reduce overall mortality at 30 days, 6-month mortality was lower in the revascularization group versus the medical therapy group (50.3% vs 63.1%; \u003Cem\u003EP\u003C\/em\u003E = .027). After 6 years, 62.4% of hospital survivors with CS who were treated with early revascularization were still alive, compared with 44.4% of those treated medically. Compared with initial medical stabilization, this represents a 13.2% absolute improvement and a 67% relative improvement in 6-year survival.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EIn the IABP-SHOCK II trial [Thiele H et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2012], 600 patients with AMI and CS were randomized to IABP plus medical therapy or medical therapy only. After 30 days, all-cause mortality was similar between 2 groups\u201441.3% versus 39.7% in the control and IABP groups, respectively (log-rank \u003Cem\u003EP\u003C\/em\u003E = .92).\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EMechanical devices such as the Impella, the TandemHeart, and extracorporeal life support (ECLS; also known as extracorporeal membrane oxygenation [ECMO]) have recently gained popularity as replacements for IABP. The Impella is a miniaturized pump motor that is placed into the left ventricle with inlet and outlet holes straddling the aortic valve. It is delivered via a standard catheterization procedure through the femoral artery (Impella 2.5 and Impella CP) or, in the case of the Impella 5.0, via femoral cutdown or through the axillary artery. The pump pulls blood from the left ventricle through an inlet area near the tip and expels blood from the catheter into the ascending aorta. Axial flow ranges from 2.5 to 5.0 L\/min for the Impella 2.5 and 5.0; the Impella CP can deliver 3.5 to 4 L\/min.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EIn the ISAR-SHOCK trial [Seyfarth M et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2008], the Impella 2.5 reduced lactate and provided superior HD support when compared with the IABP, although hemolysis was a problem. This study included only 26 patients, and there are no public data for the Impella 5.0 or CP. While there are no clinical data showing an improvement in survival, the US Impella registry for AMI noted that patients receiving the Impella device pre\u2013percutaneous coronary intervention (PCI) had significantly better survival-to-discharge rates when compared with patients receiving the device post-PCI (65.1% vs 40.7%; \u003Cem\u003EP\u003C\/em\u003E = .003) [O\u0027Neill WW et al. \u003Cem\u003EJ Interv Cardiol.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThe TandemHeart is a percutaneous bypass device\u2014left atrial to iliac artery\u2014powered by an external centrifugal pump that provides up to 3.5 to 4 L\/min of forward flow. To access the left atrium as well as the iliac artery, arterial and venous access must be obtained at the femoral vessels [Naidu SS. \u003Cem\u003ECirculation.\u003C\/em\u003E 2011]. There have been no large-scale clinical trials with this device, but there is some evidence that it provides effective HD support superior to IABP (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). The technically demanding insertion technique has been the limiting factor for a more widespread use.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16922\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16922\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16922\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003ETandemHeart Provides Superior Hemodynamic Results Relative to IABP\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-12\u0022\u003EECLS\/ECMO is a percutaneous cardiopulmonary bypass system that provides complete support of cardiac output and respiratory function. Femoral or neck access and both arterial and venous access are possible. Although insertion is not time-consuming, a perfusionist is needed. To date, no randomized study data are available for ECLS\/ECMO use in CS.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EObservational data suggest that timing of implantation is critical. A door-to-ECLS implantation time of \u0026lt; 30 minutes, as compared to \u0026gt; 30 minutes, significantly (\u003Cem\u003EP\u003C\/em\u003E = .012) improves 30-day outcomes in patients with out-of-hospital cardiac arrest (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Leick J et al. \u003Cem\u003EClin Res Cardiol.\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Impact of Time to ECLS Implantation on 30-Day Survival\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-389031653\u0022 data-figure-caption=\u0022Impact of Time to ECLS Implantation on 30-Day Survival\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16920\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EImpact of Time to ECLS Implantation on 30-Day Survival\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EECLS, extracorporeal life support.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EAdapted from Clinical Research in Cardiology, 102, 2013, 661\u2013669. Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest. Lieck J et al. Fig 1. \u00a9 Springer-Verlag Berlin Heidelberg 2013. With kind permission from Springer Science and Business Media.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-15\u0022\u003EThere are 2 strategies for ECLS use. The first focuses on acute stabilization, short-term transfer, and moratorium of decision. Duration of support is \u0026lt; 72 hours, with rapid deployment of nondurable technology. The second is an integrated program with a focus on recovery and using ECLS as a bridge to transplant. Duration of support is \u0026gt; 72 hours and requires extended infrastructure and durable technologies.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EWhile data showing good outcomes with ECLS are limited, there is cause for optimism. In a recent study of the 218 patients who went into shock on ECMO, 146 survived, and 122 (53.5%) were successfully discharged (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Loforte A et al. \u003Cem\u003EArtif Organs.\u003C\/em\u003E 2014]. While this observation is nonrandomized and with no comparison, the rates of survival appear encouraging when compared to the known natural history of CS.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Number of Patients Who Survived and Were Discharged Following ECLS\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-389031653\u0022 data-figure-caption=\u0022Number of Patients Who Survived and Were Discharged Following ECLS\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/4\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16921\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \u003Cp id=\u0022p-17\u0022 class=\u0022first-child\u0022\u003ENumber of Patients Who Survived and Were Discharged Following ECLS\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EECLS, extracorporeal life support; ECMO, extracorporeal membrane oxygenation.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-5\u0022\u003ESource: Loforte A et al. \u003Cem\u003EArtif Organs\u003C\/em\u003E. 2014. Reproduced with permission from KM Ziada, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-18\u0022\u003EBleeding, arterial injury, hemolysis, thrombocytopenia, and transseptal puncture are some of the complications noted with the use of mechanical devices.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003ECS is highly fatal in patients with AMI and requires rapid diagnosis and mechanical reperfusion to improve survival. The primary objective is to save brain and kidney function. Mechanical support, a mainstay of HD maintenance, is an important tool for the management of profound shock or cardiovascular collapse. Timing of mechanical device implantation and patient selection are critical for success. Technologies such as ECLS are promising, but such devices can be technically challenging and have a learning curve. Additional data are required to determine if the various forms of mechanical support affect mortality.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/16\/4.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzljw1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzljw1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzljw1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}