Hemodynamic support in cardiogenic shock

Cardiogenic shock has a poor survival rate that has not significantly improved over the past decades. The aims of this thesis were to evaluate current and new therapies and to determine factors that are associated with mortality in cardiogenic shock. In Part I we focus on cardiogenic shock in the Netherlands and describe current treatment strategies. Part II evaluates mechanical circulatory support with the Impella. Part III comprises two chapters in which the Impella and ECMO system are compared in patients with cardiogenic shock. Part IV focusses on mechanical circulatory support with the ECMO system. The main findings of the work included in this thesis are that (1) pharmacologic therapy is routinely administered without strong clinical evidence derived from trials; (2) thus far none of the available mechanical circulatory support devices have shown better clinical outcome in the limited randomized trials available. In addition, in this thesis none of these devices are superior over the other with respect to better survival, based on data derived mostly from observational studies; (3) device-related complications, such as major bleeding, occur frequently in patients with mechanical circulatory support; (4) early initiation of Impella support may reduce cardiac mortality, compared with delayed initiation; (5) several factors are associated with increased mortality: higher age, higher lactate level, lower pH level, renal insufficiency, out-of-hospital cardiac arrest, multivessel disease, diabetes mellitus and prior myocardial infarction. Lastly, several recommendations are made for future research in cardiogenic shock based on the current knowledge gaps and work presented in this thesis.