Intra-aortic Balloon Counterpulsation Research Articles

Standard Intra-Aortic Counterpulsation Balloon May Cause Temporary Occlusion of Mesenterial and Renal Arteries

The study was to test the hypothesis that mesenteric and renal arteries may be occluded by intra-aortic balloon pumps (IABPs), despite correct positioning. Computed tomography scans of 107 patients (34.6% women and 65.4% men) were evaluated for diameter and distance measurements of the descending aorta. Renal perfusion was examined with duplex sonography. Mean distances between left subclavian artery and celiac trunk, between the left subclavian and superior mesenteric artery, and between the left subclavian and renal artery were 214.5 ± 22.3, 229.5 ± 22.3, and 242.9 ± 22.1 mm, respectively. Statistical assessment of aortic distances in patient population showed no correlation between the length of the descending aorta and body mass index (BMI) and height (men: R(2) < 0.13; women: R(2) < 0.3). An impaired arterial perfusion of the renal parenchyma existed in three of the 12 patients; three of the 12 demonstrated diastolic oscillatory flow over the renal arteries; two of the 12 patients presented both during IABP support. Autopsy observation was used to observe the position of the IABP catheter. The correlation between patient height/BMI and the distances between subclavian artery and renal/visceral branches is weak. Therefore, even if positioned correctly, intra-aortic balloon catheters may be too long and could potentially cause occlusion of aortic branches.

Intra-aortic balloon counterpulsation in acute myocardial infarction: old and emerging indications

BackgroundRecent evidence questions the role of intra-aortic balloon counterpulsation (IABP) in the treatment of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). An area of increasing interest is the use of IABP for persistent ischaemia (PI). We analysed the use of IABP in patients with AMI complicated by CS or PI.MethodsFrom 2008 to 2010, a total of 4076 patients were admitted to our hospital for primary percutaneous coronary intervention (PCI) for AMI. Out of those, 239 patients received an IABP either because of CS or because of PI. Characteristics and outcome of those patients are investigated.ResultsThe mean age of the study population was 64 ± 11 years; 75 % were male patients. Of the patients, 63 % had CS and 37 % had PI. Patients with CS had a 30-day mortality rate of 36 %; 1-year mortality was 41 %. Patients with PI had a 30-day mortality rate of 7 %; 1-year mortality was 11 %.ConclusionsMortality in patients admitted for primary PCI because of AMI complicated by CS is high despite IABP use. Outcome in patients treated with IABP for PI is favourable and mandates further prospective studies.

It's Official: IABP Does Not Improve Mortality in Acute MI Patients with Shock

Short-term data from the IABP-SHOCK II trial (NEJM JW Cardiol Aug 27 2012) showed no survival benefit with intra-aortic balloon counterpulsation (IABP)

PASSIVE COUNTERPULSATION: BIOMECHANICAL RATIONALE AND CLINICAL VALIDATION

Intra-aortic balloon counterpulsation (IABP) is the leading technique for cardiovascular support in most critical conditions. The beneficial effects of the procedure are widely known, but some drawbacks remain unsolved: high cost and controversial effect in presence of cardiac arrhythmia, both related to the control of intra-aortic balloon inflation and deflation. This paper describes the clinical validation of a completely passive solution (PIABP), which substitutes the time-controlled pumping system by a simple pressure-controlled reservoir. The test was performed on 10 patients, switching from IABP to PIABP and changing the reservoir pressure to obtain an optimal effect in terms of mean aortic pressure increase as an estimate of cardiac output. For each patient the reservoir pressure was increased in 10 mmHg steps and the aortic pressure was recorded together with electrocardiogram. The PIABP showed a positive effect in all the patients, with a significant increase of the mean aortic pressure (+6.5%, p &lt; 0.05) and of the mean pressure of the aortic pulse diastolic phase (+7%, p &lt; 0.05). The change of heart rate between basal and optimal effect condition was not significant. Also an unexpected, significant increase of aortic maximal pressure (8%, p &lt; 0.05) was found. The proposed passive solution cannot be a substitute of the active one in all the situation, but may be useful in border line conditions, where the IABP is no more necessary but a ventricular support is still desirable.

TCT-446 Effect of Intra-Aortic Balloon Counterpulsation on Short-Term Survival in Cardiogenic Shock due to Acute Coronary Syndromes

To compare the outcome of percutaneous coronary intervention (PCI) treatment with intra-aortic balloon counterpulsation (IABP) versus PCI without IABP on 30-days survival in patients with cardiogenic shock (CS) due to acute coronary syndromes (STEMI and non-STEMI). We extracted data for all

Evaluating Current Practice and Outcomes of Therapeutic Anticoagulation During Intra-Aortic Balloon Counterpulsation in a Coronary Care Unit JL Bong, EH Law, SL Koshman, WJ Tymchak, AM Moghrabi, ML Ackman

Therapeutic anticoagulation for intra-aortic balloon pumps (IABP) in coronary care unit patients is commonly utilized. A more selective strategy for anticoagulation (i.e. only patients with another primary indication for systemic anticoagulation receive heparin) has been suggested to minimize bleeding. A current review of IABP practice with respect to anticoagulation, patient population and its associated risks is timely.

293 * EXTRACORPOREAL LIFE SUPPORT FOR CARDIOGENIC SHOCK: INFLUENCE OF CONCOMITANT INTRA-AORTIC BALLOON COUNTERPULSATION

OBJECTIVES: Intra-aortic balloon counterpulsation (IABP) during extracorporeal life support (ECLS) for cardiogenic shock may improve pulsatility and coronary perfusion, thereby promoting recovery of cardiac function. However, the risks and benefits of IABP during ECLS in real clinical settings have not been evaluated. This study aims to evaluate the effect of IABP on the early outcome of ECLS for cardiogenic shock. METHODS: We evaluated 253 adult patients (aged 58.8 ± 15.3 [mean ± standard deviation] years, 154 males) undergoing ECLS for cardiogenic shock from January 2005 to August 2012. Of them, 60 patients underwent concomitant IABP (IABP group) and 193 underwent ECLS only (control group). In-hospital outcomes were compared using the inverse probability of treatment weighting based on propensity scores. RESULTS: The indications for ECLS were low cardiac output after cardiac surgery in 118 patients (46.6%), heart failure in 71 (28.1%), acute myocardial infarction in 49 (19.4%) and others in 15 (5.9%). Successful ECLS weaning rate was significantly higher in the IABP group than in the control group (61.7 vs 42.0%, P= 0.008); however, there was no significant difference in in-hospital mortality between the two groups (68.6 vs 72.0%, P= 0.58). After adjustment for propensity of treatment assignment conditional on baseline characteristics, the IABP group showed a decreased risk of weaning failure (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.28–0.92, P= 0.024) but with a similar risk of in-hospital mortality (OR 0.85; 95% CI 0.46–1.60; P= 0.62) compared with the control group. CONCLUSIONS: The use of IABP during ECLS increased a successful ECLS weaning rate, but was not translated into improved survival. Studies on larger populations may verify the survival effect of IABP during ECLS.

Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial

In current international guidelines the recommendation for intra-aortic balloon pump (IABP) use has been downgraded in cardiogenic shock complicating acute myocardial infarction on the basis of registry data. In the largest randomised trial (IABP-SHOCK II), IABP support did not reduce 30 day mortality compared with control. However, previous trials in cardiogenic shock showed a mortality benefit only at extended follow-up. The present analysis therefore reports 6 and 12 month results. The IABP-SHOCK II trial was a randomised, open-label, multicentre trial. Patients with cardiogenic shock complicating acute myocardial infarction who were undergoing early revascularisation and optimum medical therapy were randomly assigned (1:1) to IABP versus control via a central web-based system. The primary efficacy endpoint was 30 day all-cause mortality, but 6 and 12 month follow-up was done in addition to quality-of-life assessment for all survivors with the Euroqol-5D questionnaire. A masked central committee adjudicated clinical outcomes. Patients and investigators were not masked to treatment allocation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00491036. Between June 16, 2009, and March 3, 2012, 600 patients were assigned to IABP (n=301) or control (n=299). Of 595 patients completing 12 month follow-up, 155 (52%) of 299 patients in the IABP group and 152 (51%) of 296 patients in the control group had died (relative risk [RR] 1·01, 95% CI 0·86-1·18, p=0·91). There were no significant differences in reinfarction (RR 2·60, 95% CI 0·95-7·10, p=0·05), recurrent revascularisation (0·91, 0·58-1·41, p=0·77), or stroke (1·50, 0·25-8·84, p=1·00). For survivors, quality-of-life measures including mobility, self-care, usual activities, pain or discomfort, and anxiety or depression did not differ significantly between study groups. In patients undergoing early revascularisation for myocardial infarction complicated by cardiogenic shock, IABP did not reduce 12 month all-cause mortality. German Research Foundation; German Heart Research Foundation; German Cardiac Society; Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte; University of Leipzig--Heart Centre; Maquet Cardiopulmonary; Teleflex Medical.

Impact of intraaortic balloon counterpulsation in patients with acute myocardial infarction and cardiogenic shock

Purpose: Intraaortic balloon counterpulsation (IABP) is recommended for acute myocardial infarction (MI) patients who presenting with cardiogenic shock. Recently, a randomized trial revealed that IABP support did not reduce 30-day mortality. We aimed to determine the impact of IABP support on the short- and long-term mortality. Methods: A total of 774 patients with acute MI and cardiogenic shock were selected from the Korea Working Group on Myocardial Infarction Registry between December 2007 and December 2010. Primary outcomes were mortality at one-month and one-year. Results: The patients who were treated with IABP support was 395 and the patients not treated with IABP was 379. The patients treated with IABP were more ST-segment elevation myocardial infarction, anterior ischemia on electrocardiogram, and had undergone more PCI and coronary artery bypass surgery than patients not treated with IABP. Infarct area was larger and rate of statin prescription during hospitalization was higher in patients treated with IABP. One-month mortality and one-year mortality were significantly lower in patients treated with IABP compared to patients not treated with IABP (45.3 vs 54.6%, p=0.024; 46.8 vs 55.4%, p=0.041, respectively). By multivariate logistic regression analysis after adjusting confounding variables, IABP support was associated with neither one-month mortality nor one-year mortality (OR 0.62, 95% CI 0.348-1.098, p=0.101; OR 0.64, 95% CI 0.382-1.085, p=0.098, respectively). However, Cox proportional hazard model showed that long-term survival was significantly better in patients treated with IABP (log rank p=0.034). ![Figure][1] Conclusions: This study showed that IABP support was not associated with reduced one-month mortality but associated with long-term mortality benefit. [1]: pending:yes

Current use and clinical benefit of intraaortic balloon support in patients with ST-elevation myocardial infarction complicated by cardiogenic shock

Background: European guideline recommendations for the use of intraaortic balloon support in patients with STEMI complicated by cardiogenic shock have just been revised. We sought to evaluate current use and clinical benefit of intraaortic balloon support in clinical practice. Methods: Between 2007 and 2012 a total of 4065 consecutive patients presenting with STEMI were enrolled in the FITT-STEMI feasibility-trial. 6 primary percutaneous coronary intervention hospitals in Germany and 29 associated nonpercutaneous coronary intervention hospitals participated. Data from patient contact to balloon inflation were collected and analyzed. For the present study we evaluated the FITT-STEMI-trial and included all patients with STEMI complicated by cardiogenic shock in our analysis. Results: STEMI was complicated by cardiogenic shock in 10% (406/4065) of the patients. Hospital mortality in those patients was 44% (179/406). 40.4% (164/406) of the patients with STEMI complicated by cardiogenic shock were treated with intraaortic balloon counterpulsation. Hospital mortality did not differ between patients receiving or not receiving intraaortic ballon support (43.3% vs. 44.6%). Conclusion: Hospital mortality in patients with STEMI complicated by cardiogenic shock is still high, despite high use of early reperfusion therapy. Almost half of the patients admitted with STEMI complicated by cardiogenic shock received intraaortic balloon support. However, the use of intraaortic ballon support was not associated with a lower hospital mortality which supports the findings of the randomized IABP-Shock II trial.

Current State of Clinical Translation of Cardioprotective Agents for Acute Myocardial Infarction

There is continued interest in the concept of limiting myocardial infarct size with adjunctive agents administered along with reperfusion injury; however, there remains considerable controversy in the literature. The purpose of this article is to review the medical literature on clinical trials performed during the past 3 years that have attempted to reduce myocardial infarct size by administration of adjunctive therapies along with reperfusion therapy. A PubMed-driven literature search revealed a host of clinical trials focusing on the following prominent types of therapies: endogenous conditioning (postconditioning and remote ischemic conditioning); rapid cooling; pharmacological therapy (cyclosporine, abciximab, clopidogrel, tirofiban, erythropoietin, thrombus aspiration, adenosine, glucose-insulin-potassium, statins, antidiabetic agents, FX06, iron chelation, and ranolazine). Although there remains some controversy, quite a few of these studies showed that adjunctive therapy further reduced myocardial infarct size when coupled with reperfusion. Antiplatelet agents are emerging as some of the newest agents that seem to have cardioprotective capabilities. Postconditioning has become a bit more controversial in the clinical literature; remote conditioning, early and rapid cooling, adenosine, and ranolazine are intriguing therapies deserving of larger studies. Certain agents and maneuvers, such as erythropoietin, protein kinase C δ inhibitors, iron chelation, and intra-aortic balloon counterpulsation, perhaps should be retired. The correct adjunctive therapy administered along with reperfusion has the capability of further reducing myocardial injury during ST-segment-elevation myocardial infarction.

GW24-e0251 Coronary angiography in cardiogenic shock complicated with acute myocardial infarction

ObjectivesTo study the coronary angiographic features of patients with cardiogenic shock complicating acute myocardial infarction (AMI).MethodsOne hundred and fifty-two consecutive patients with AMI were included in this study. The characteristics,...

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Importance of Total Ischemic Time and Preprocedural Infarct-Related Artery Blood Flow in Predicting Infarct Size in Patients With Anterior Wall Myocardial Infarction (from the CRISP-AMI Trial)

The goal of this study was to characterize determinants of infarct size in the multicenter randomized Counterpulsation to Reduce Infarct Size Pre-PCI Acute Myocardial Infarction (CRISP-AMI) trial. Contemporary determinants of infarct size in patients presenting with acute anterior myocardial infarction without shock and undergoing percutaneous revascularization have been incompletely characterized. In CRISP-AMI, 337 patients with acute anterior ST segment elevation myocardial infarction but without cardiogenic shock at 30 sites in 9 countries were randomized to initiation of intra-aortic balloon counterpulsation before primary percutaneous coronary intervention versus standard of care. The primary outcome was infarct size as measured by cardiac magnetic resonance imaging 3 to 5 days after percutaneous coronary intervention. Of 337 randomized patients, complete periprocedural and infarct size data were available in 250 patients (74%). After a comparison of baseline characteristics to ensure no significant differences, patients with missing data were excluded. Using multiple linear regression of 23 variables, time from symptom onset to first device (β = 0.022, p = 0.047) and preprocedural Thrombolysis In Myocardial Infarction flow 0/1 (β = 15.28, p <0.001) were independent predictors of infarct size. Infarct size increased by 0.43% per 30 minutes in early reperfusion and by 0.63% every 30 minutes in late reperfusion. In conclusion, in patients with acute anterior ST elevation myocardial infraction without cardiogenic shock, total ischemic time and preprocedural Thrombolysis In Myocardial Infarction flow 0/1 were associated with increased infarct size as determined by cardiac magnetic resonance imaging. These findings underscore the importance of systems of care aimed at reducing total ischemic time to open infarct arteries.

Intra-aortic Balloon Pump Trials

Clinical experience with the intra-aortic balloon pump (IABP) spans >40 years.1 Physiological studies have demonstrated that the IABP acutely improves systemic hemodynamics, augments coronary flow, reduces myocardial oxygen demand, and can sustain coronary patency after percutaneous revascularization.2–4 These sound physiological principles, largely supportive observational data,5–7 and a historical lack of alternative percutaneous devices to provide circulatory support led to the widespread use of the IABP in cardiogenic shock secondary to acute myocardial infarction (AMI), ST-segment elevation-acute coronary syndrome without shock and also in high-risk percutaneous coronary intervention (PCI), despite a paucity of adequately powered randomized evidence to support their use. Nearly 5 decades since the introduction of IABP into clinical practice, we finally have randomized data on the efficacy of balloon counterpulsation for each of the 3 above indications.8–10 The main clinical applications for counterpulsation and the randomized data for each indication are summarized in the Table. View this table: Table. Randomized Control Trials of Intra-aortic Balloon Counterpulsation To the surprise of many who have come to rely on the support and reassurance provided by this device, none of the recent trials reached their primary efficacy end points. Where does that leave us with the IABP? Is it time to abandon ship or is there hope yet for an old friend? Perhaps the most surprising of these randomized controlled trial (RCT) results was from the most recent trial, IABP-SHOCK II.8 This multicenter, open-labeled, randomized study enrolled 600 patients with AMI (with or without ST-segment elevation) with cardiogenic shock, if early revascularization was planned. Patients were randomized in a 1:1 ratio to intra-aortic balloon counterpulsation (IABP group) or no intra-aortic counterpulsation (control group). The primary study end point, 30-day all-cause mortality, occurred in a similar proportion of the IABP and control groups (39.7% …

Observation and nursing of IABP combined with ECMO treatment for patients with low cardiac output syndrome after cardiac surgery

Objective To summarize the nursing experience of using intra-aortic balloon counterpulsation (IABP)and extracorporeal membrane oxygenation (ECMO) for patients with low cardiac output syndrome after cardiac surgery.Methods Fourteen patients with postoperative low cardiac output syndrome were treated with IABP and ECMO,and clinical and nursing data was retrospectively analyzed.By observing changes of the parameters of hemodynamics before and after,treatment effect was evaluated and nursing experience was summarized.Results Parameters of hemodynamics improved significantly after combined treatment [SBP:(110.8 ± 11.8) mm Hg / (76.7 ± 18.1) mm Hg; DBP:(60.3 ± 11.2) mmHg / (48.5 ±9.5) mm Hg; LVEF:(0.48 ± 0.02) mmHg / (0.30 ± 0.02)mm Hg],and the differences were statistically significant(t =-5.732,-3.449,-6.192,respectively ;P ＜ 0.05).Index of arterial blood gas also improved [pH:(7.39 ± 0.18) / (7.28 ± 0.08) ; PaO2:(132.02 ± 27.96) mm Hg / (82.71 ± 28.32) mm Hg],and the differences were statistically significant (t =-2.650,-3.690,respectively; P ＜ 0.05).Urine volume with 24 h increased from (1 254.17 ±861.19) ml to(2 588.5 ± 1 360.82) ml,and the difference was statistically significant (t =-3.419,P ＜ 0.05).9 patients were discharged from hospital smoothly.Conclusions IABP combined with ECMO treatment provides an effective option to rescuer patients with low cardiac output syndrome after cardiac operation.Strict monitoring and in-time adjustment of nursing methods are important steps during nursing process. Key words: Intra-aortic balloon counter-pulsation; Extracorporeal membrane oxygenation; Nursing

The Hemodynamic Effects of the MEGA Intra-Aortic Balloon Counterpulsation Pump

Purpose The IABP-SHOCK II study recently questioned the clinical utility of intra-aortic balloon counterpulsation (IABP) in patients with acute myocardial infarction and cardiogenic shock. The aim of this study was to compare the hemodynamic effect of the MEGA-series (50cc) and standard (40cc) IABPs (Maquet Inc). Methods and Materials Twenty consecutive subjects treated with a MEGA-IABP between January and November 2012 were studied. Twenty age-, gender-, and body surface area matched patients receiving a 40cc standard IABP during the same time period served as controls. All subjects presented with decompensated left heart failure or cardiogenic shock. Medical records were reviewed for demographics, hemodynamic data, laboratory data, and clinical outcomes. Hemodynamic and laboratory datat were collected within 24 hours of IABP placement. Results Demographics, hemodynamics and laboratory values are shown in Table One . Baseline characteristics were similar between groups except for a higher incidence of diabetes mellitus in the MEGA group (76% vs 33%, p Conclusions Use of the 50cc MEGA-IABP is associated with improved systemic hemodynamic variables compared to the standard 40cc IABP. Further investigation into the clinical utility of the MEGA IABP is required.

Radial approach and single wiring as first intentional strategies in chronic total occlusions of the left anterior descending coronary artery

BackgroundPercutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of the left anterior descending coronary artery (LAD) specifically is associated with improved long-term 5years survival as compared to PCI failure. Simpler PCI techniques may be successful and safer than complex techniques which are perceived to have high failure rates and technical complexity.We aimed to describe the safety and effectiveness of first intentional single wiring and radial approach in the treatment of patients with a CTO of the native LAD coronary artery at Toulouse Rangueil university hospitals. Patients and methodsThe study was a single center prospective registry. All patients showed evidence of myocardial viability in LAD territory. The operators’ initial strategy was to start by a radial access as a first choice whenever feasible; if not, a femoral access was chosen. The initial strategy for lesion crossing in either antegrade or retrograde approaches was single wiring by lesion crossing using one guidewire (GW) as a simple technique. ResultsA total of 30 patients with 30 LAD CTO lesions (100%) were recorded. Mean age was 71.6+15years, 77% were males and 23% were females. The access route was radial 66% of the time and femoral 54% of the time and with double access for contralateral injection in 40% of the patients. Sheaths and catheters sizes 6F were used in 53% of the patients, and 7F in 73% of the patients.Overall lesion success rate was 83% of lesions. Single wiring was the prevailing technique used in 97% of successful lesions (83% of total cases), while only 3% were by multiple wiring techniques. Successful single antegrade wiring represented 63% of our total study cases with a GW success rate of 92% of cases. Successful single retrograde wiring represented 13% of our cases with a GW success rate of 67%. Q-wave myocardial infarction (MI), stent thrombosis, stroke, emergency coronary artery bypass graft (CABG), major bleeding, radiation dermatitis, cardiac tamponade or clinical perforation requiring any hemostatic maneuvers did not occur. There was a post-procedural Troponin rise of 3x normal levels in 30% of patients, and contrast induced nephropathy in 7%. Intra-aortic balloon counterpulsation (IABCP) was used in 3% of patients and cardiac death occurred in 3% of patients. ConclusionSingle wiring and radial access as initial strategies in PCI for LAD-CTO lesions in either approaches antegrade or retrograde are associated with a high procedural success rate and an acceptable incidences of adverse events.

Prophylactic implantation of intra-aortic balloon counter-pulsation improves outcome in high-risk cardiac surgery patients – fact or fantasy?

Prophylactic implantation of intra-aortic balloon counter-pulsation improves outcome in high-risk cardiac surgery patients – fact or fantasy?

Influence of Gender on Postoperative Outcome after Intra-aortic Balloon Counter-Pulsation and Cardiac Surgery

Female gender is an established risk factor for worse outcomes after cardiac surgery, and women are more likely to experience postoperative complications. Our aim was to analyze the influence of gender on outcome and postoperative complications after the use of intra-aortic balloon counter-pulsation (IABP) in cardiac surgery patients. Fifty-seven consecutive female patients (mean age: 73 ± 9 years) requiring an IABP at our department from January 2007 to January 2010 were retrospectively analyzed and compared with 182 male patients receiving IABP support within the same period. The collected data included patient demographics, preoperative state, operative details, postoperative pharmacological treatment, IABP-associated complications, and inhospital mortality. Preoperative mortality risk was calculated by logistic EuroSCORE. There were no differences regarding the type of operation, preoperative renal or hepatic failure, though the prevalence of peripheral artery occlusive disease was higher in men. Furthermore, female patients receiving an IABP were significantly older (73 ± 9 vs. 67 ± 10 years), had a higher ejection fraction (EF) (45% ± 24% vs. 36% ± 14%), and had a higher EuroSCORE (25% ± 20% vs. 19% ± 17%; p < 0.05). Postoperative catecholamine support was significantly higher in the female patients. Women had a prolonged length of stay (LOS) at the ICU (10.64 ± 9.7 vs. 7.6 ± 7.6 days), higher incidence of renal replacement therapy, and a higher mortality (19 [19.4%] vs. 35 [33.9%]; p < 0.05) after the use of IABP. Women have a worse outcome after the use of IABP, including LOS at the ICU, postoperative renal failure, and inhospital mortality, despite higher EF, when compared with men.