Which role today for intra-aortic balloon counterpulsation?

Abstract

Intra-aortic balloon pump (IABP) is a percutaneous assist device that is easy to implant, is associated with low complication rates and, therefore, is widely used. It is commonly applied by femoral access, although it can be used with axillary access. It reduces afterload and preload, with a slight increase in mean arterial pressure and coronary perfusion. For these characteristics, it has been extensively used in cardiogenic shock, even without a clear demonstration of efficacy from randomized clinical trials; the IABP-SHOCK II study, the largest trial carried out so far, failed to demonstrate the usefulness of IABP in this setting. Furthermore, the routine use of IABP in patients with acute anterior myocardial infarction was not associated with any benefit in reducing ischemic area at cardiac magnetic resonance, as shown by the CRISP-AMI trial. For these reasons, the international guidelines do not support the routine use of IABP in acute myocardial infarction complicated by cardiogenic shock, suggesting instead its use in different scenarios such as heart failure associated with acute mechanical complications or acute myocarditis. IABP is currently used in patients undergoing percutaneous coronary interventions or surgical coronary revascularization judged at high risk of complications. In the former scenario, the evidence from the literature is very scarce; in the latter one, small trials and meta-analytical studies suggest a treatment benefit with IABP in the preoperative period.Despite limited evidence of efficacy, IABP will continue to play an important role in today's cardiology and is going to remain the most widely used mechanical circulatory support device.