Severe Right Ventricular Dysfunction Predicts Failure of Intra-Aortic Balloon Pump Hemodynamic Support in Cardiogenic Shock

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Introduction We previously showed that ischemic history and low left ventricular cardiac power index (LVCPI) predict failure of intra-aortic balloon pump (IABP) hemodynamic support in cases of acute decompensated heart failure complicated by cardiogenic shock. We hypothesized that right ventricular (RV) systolic dysfunction would further impact the adequacy and outcomes of IABP hemodynamic support. Methods We retrospectively studied 74 patients who underwent IABP insertion for treatment of cardiogenic shock not related to acute myocardial infarction. Severity of RV systolic dysfunction, based on echocardiographic assessment, ranged from none to severe. Poor outcomes from IABP support included death or need for unplanned upgrade of mechanical circulatory support. Successful outcomes included bridge to recovery, transplant, or left ventricular assist device. Multivariable regression and Cox proportional hazard ratios were also used to study outcomes. Results Severe RV systolic dysfunction on echocardiogram was found in 10 patients (13.5%). Severe RV dysfunction, when compared to patients with no or mild RV dysfunction, was associated with increased right atrial pressure (RAP) (20.6±6 vs. 16.2±5.9 mmHg, p=0.04) and lower RV stroke work index (3.2±2.0 vs. 5.5±3.4 g/m, p=0.046) at time of IABP placement. After 48 hours of IABP support, patients with severe RV dysfunction continued to have higher RAP (18.9±8.5 vs. 12.2±4.7 mmHg, p=0.03), as well as worsened pulmonary artery pulsatility index (1.3±0.7 vs. 2.6±2.4, p=0.048) and RAP/pulmonary capillary wedge ratio (1.1±0.7 vs. 0.7±0.3, p=0.01). Severe RV systolic dysfunction independently predicted poor outcomes (OR 8.5, p=0.01), even when adjusted for LVCPI and ischemic history. An IABP failure risk score using all 3 variables (severe RV dysfunction, LVCPI, and ischemic history) predicted 28-day outcomes with excellent discrimination (Figure 1). Conclusions Severe RV systolic dysfunction corresponds with poor right-sided hemodynamics at baseline and following IABP support, and may predict failure of IABP hemodynamic support. Severe RV systolic dysfunction complicating cardiogenic shock likely warrants up-front consideration of biventricular support instead of IABP alone.