Intra-aortic Balloon Pump Counterpulsation Research Articles

Use of left ventricular support devices during acute coronary syndrome and percutaneous coronary intervention.

In an effort to improve outcomes in percutaneous coronary intervention (PCI), percutaneous ventricular assist devices (PVADs) have been investigated in (1) high-risk PCI, (2) acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) and (3) in AMI without CS. PCI has become an increasing complex due to an ageing population with complex disease and the frequent presence of impaired LV function. Patients undergoing high-risk PCI in these circumstances are prone to acute cardiovascular collapse. Additionally, mortality in AMI complicated by CS remains high. Lastly, LV support during AMI may reduce infarct size and therefore preserve LV function. At present, four commercially available devices exist: intra-aortic balloon pump counterpulsation (IABP), Impella, TandemHeart and extracorporeal membrane oxygenation (ECMO). These devices are employed in an effort to increase cardiac output, mean arterial pressure (MAP) and coronary perfusion and to reduce pulmonary capillary wedge pressure (PCWP). The mechanism of action differs with each device, and there are advantages and disadvantages. In this update, we discuss recent data describing the use of PVADs to support patients with AMI with or without cardiogenic shock and during high-risk PCI. We focus on the unique features of each device, highlighting strengths, weaknesses and frequently encountered complications, which may be important when tailoring the most appropriate PVAD therapy to an individual patient's need.

Incomplete leaflet coaptation and tricuspid regurgitation mechanism in right ventricular Tako-Tsubo cardiomyopathy

Tako-Tsubo cardiomyopathy (TTC) is a well-known form of acuteand reversible heart failure due to either an emotional or a physicalstressor,whichinvolvesmainlytheleftventriclewithatypicalechocar-diographic pattern (apical ballooningand basal hyperkinesis) [1].Rightventricular(RV)involvementhasaprevalenceof25%[2].Aclinicalcase,a short literature review and possible explaining mechanism areprovided.An86-yearoldwoman,withoutcardiovascularriskfactorsandwithhistory of bipolardisorder [3] cameto the emergency department afteran episode of syncope. At admission blood pressure was 70/50 mm Hg,ECG showed atrial fibrillation and ST-elevation in anterior and lateralleads (V2–V4, DI, aVL) (Fig. 1). Troponin I levels were increased(4.54 ng/ml, n.v. b 0.10). Trans-thoracic echocardiogram showed leftventricular (LV) systolic dysfunction (ejection fraction of 25%),akinesisofLVmidventricularsegments,dyskinesisofRVapicalsegmentsandin-complete coaptation of tricuspid leaflets (Video 1). At color-Dopplermild mitral regurgitation and severe tricuspid regurgitation werefound (Figs. 2 and 3, Video 2). Coronary angiography showed diffuseatherosclerosis not needing coronary intervention. Echocardiographyanomalies gradually recovered and the patient was discharged after acouple of weeks (Figs. 4 and 5) (Video 3). Discharge electrocardiogramshowed negative T-waves in anterior leads previously interested byST-elevation and diffuse decrease in QRS amplitude [4].Despite TTC affects mainly left ventricle, RV involvement is presentinoneoutoffourpatientsaffectedbyTTC.Severalechocardiographicstudies described acute mitral regurgitation and its clinical impor-tance in TTC[5], but, to the best of our knowledge, possible mecha-nism of tricuspid regurgitationduring RV TTC was never describedbefore.We report a case of RV apical dyskinesis causing traction of thepostero-lateral papillary muscle and consequent compromised coapta-tion of thetricuspid valve leaflets (Fig. 2);that could have led to severetricuspid regurgitation completely reversible after RV recovery.The mechanism of RV regurgitation seems to be different from thatwe have previously described in the left ventricle. LV basal hyperkinesis, consequent mitral valve area reduction and mitral leafletsredundancy may lead to LV outflow tract obstruction, increased intraventricular pressure and mitral regurgitation [6,7]. Systolic anteriormotion and tethering have been shown as independent predictors ofacute mitral regurgitation in patients with TTC [8].In thecaseof mid-LVballooning, rightward movement of midseptalsegmentsmayhaveincreasedRVpressure,thusimpairingRVgeometryand kinesis, and precipitating RV ballooning.Tricuspid regurgitation has not yet been evaluated as a marker ofprognosisinTTC;however,inacutemyocardialinfarctionoftheinferiorwall, moderate tricuspid regurgitation, affecting about one third ofpatients, is a predictor of rehospitalization at one-year follow-up [9].Although no in-hospital complication was present in our case, RVsystolic dysfunction represents an independent predictor of worseprognosis and is associated with a higher rate of in-hospital complica-tion both in inferior myocardial infarction [10] and TTC [2].Haghiet al. found in 34 patients with TTC that RV involvement is associatedwith a severe impairment in LV systolic function and a higher rate ofbilateral pleural effusion [2]. Elesber et al. showed in a population of30patientswithTTCthatRVinvolvementcarriesahigherriskofseverecongestive heart failure and longer in-hospital stay [11].We therefore believe that a systematic evaluation of RV function byechocardiogram is recommended for an optimal management of pa-tients with TTC. When an impaired LVEF is associated with abnormalRV function, there is a higher risk of hemodynamic complications.Therefore a strict monitoring is required and an early therapeuticstrategy including diuretics, levosimendan infusion and intra-aorticballoon pump counterpulsation should be considered [12–14].In conclusion, RV involvement in TTC may lead to severe tricuspidregurgitationduetoincompletecoaptationofvalveleaflets.This finding

Effects of intra-aortic balloon counterpulsation pump on mortality of acute myocardial infarction.

BackgroundSeveral randomized controlled trials (RCTs) have evaluated the effect of intra-aortic balloon counterpulsation pump(IABP) on the mortality of acute myocardial infarction (AMI).ObjectivesTo analyze the relevant RCT data on the effect of IABP on mortality and the occurrence of bleeding in AMI.Data SourcesPublished RCTs on the treatment of AMI by IABP were retrieved in searches of Medline, EMBASE, Cochrane and other related databases. The last search was conducted on July 20, 2014.Study Eligibility CriteriaRandomized clinical trials comparing IABP to controls as treatment for AMI.ParticipantsPatients with AMI.Synthesis MethodsThe primary endpoint was mortality, and the secondary endpoint was bleeding events. To account for to heterogeneity, a random-effects model was used to analyze the study data.ResultsTen trials with a total population of 973 patients that were included in the analysis showed no significant difference in 2-month mortality between the IABP and the control groups. The 6-month mortality in the IABP group was not significantly lower than in the control group in the four RCTs that enrolled 59 AMI patients with CS. But in the four that enrolled AMI 66 patients without CS, the data showed opposite conclusion.ConclusionsIABP cannot reduce within 2 months and 6–12 months mortality of AMI patients with CS as well as within 2 months mortality of AMI patients without CS, but can reduce 6–12 months mortality of AMI patients without CS. In addition, IABP can increase the risk of bleeding.

Clinical Outcomes of Intra-Aortic Balloon Counterpulsation in Patients with ST Elevation Myocardial Infarction: Experience at our Tertiary Care Hospital

Background and Objectives: Intra-Aortic Balloon Pump (IABP) is device developed to augment coronary blood flow and improve systemic blood pressure in patients with circulatory failure. This study was undertaken to analyze morbidity and mortality benefit of IABP counterpulsation in patients with Acute Myocardial Infarction (AMI) Methodology: This cross-sectional study done for three years in the Department of Cardiology of a tertiary care centre in North Karnataka from June 2009 to June 2012. Prior to the commencement of the study, ethical clearance was obtained from Human Ethics Committee. A total of 82 consecutive patients presenting with cardiogenic shock were included in the study. The patients satisfying selection criteria were informed in detail about the nature of the study and a written informed consent was obtained. The patients underwent electrocardiography and echocardiography. Based on the findings the indication for IABP was determined. Results: Majority of the patients were males (85.4%) and the commonest age group was 51 to 60 years (40.2%) with the mean age of 57.73 ± 9.41 years. Most common Electrocardiogram (ECG) presentation was Anterior Wall Myocardial Infarction (AWMI) (40.2%). The commonest indication for placement of an IABP was Left Ventricular (LV) dysfunction (47.6%) and mean duration of IABP was 4 ± 1 days. Diagnostic catheterization was performed in 55 (67.1%) patients. Among them, 40 (72.7%) underwent Percutaneous Transluminal Coronary Angioplasty (PTCA) and 15 (27.3%) underwent surgery. Of the 82 patients, major IABP related complications occurred in six (7.3%) patients. The in-hospital mortality rate was 43.9% and 56.1% of the patients improved. Of the 46 patients who improved, majority (78.2%) had undergone revascularization while of the 27 patients who expired, 47.2% did not had revascularization (p=0.015). The outcome in patients who had undergone either PTCA or surgery was significantly favourable resulting in improvement (p

Effects of intra-aortic balloon pump on cerebral blood flow during peripheral venoarterial extracorporeal membrane oxygenation support.

BackgroundThe addition of an intra-aortic balloon pump (IABP) during peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) support has been shown to improve coronary bypass graft flows and cardiac function in refractory cardiogenic shock after cardiac surgery. The purpose of this study was to evaluate the impact of additional IABP support on the cerebral blood flow (CBF) in patients with peripheral VA ECMO following cardiac procedures.MethodsTwelve patients (mean age 60.40 ± 9.80 years) received VA ECMO combined with IABP support for postcardiotomy cardiogenic shock after coronary artery bypass grafting. The mean CBF in the bilateral middle cerebral arteries was measured with and without IABP counterpulsation by transcranial Doppler. The patients provided their control values. The mean CBF data were divided into two groups (pulsatile pressure greater than 10 mmHg, P group; pulsatile pressure less than 10 mmHg, N group) based on whether the patients experienced cardiac stun. The mean cerebral blood flow in VA ECMO (IABP turned off) alone and VA ECMO with IABP support were compared using the paired t test.ResultsAll of the patients were successfully weaned from VA ECMO, and eight patients survived to discharge. The addition of IABP to VA ECMO did not change the mean CBF (251.47 ± 79.28 ml/min vs. 251.30 ± 79.47 ml/min, P = 0.96). The mean CBF was higher in VA ECMO alone than in VA ECMO combined with IABP support in the N group (257.68 ± 97.21 ml/min vs. 239.47 ± 95.60, P = 0.00). The addition of IABP to VA ECMO support increased the mean CBF values significantly compared with VA ECMO alone (261.68 ± 82.45 ml/min vs. 244.43 ± 45.85 ml/min, P = 0.00) in the P group.ConclusionThese results demonstrate that an IABP significantly changes the CBF during peripheral VA ECMO, depending on the antegrade blood flow by spontaneous cardiac function. The addition of an IABP to VA ECMO support decreased the CBF during cardiac stun, and it increased CBF without cardiac stun.

Safety and Efficacy of the StarClose Vascular Closure System following 8-Fr Sheath Placement for Intra-Aortic Balloon Pump: A Single-Center Analysis of 42 Consecutive Patients

Objective: To assess the safety and efficacy of the StarClose device following intra-aortic balloon pump (IABP) counterpulsation using 8-Fr femoral sheaths. Subjects and Methods: From June 2008 to August 2012, 42 consecutive patients who received IABP implantation via common femoral artery (CFA) punctures with an 8-Fr sheath (which were then sealed with the StarClose Vascular Closure System at the bedside) were included in this retrospective single-arm study. All the patients underwent duplex control of the puncture site 24 h after deployment of the device, in order to determine the presence or absence of vascular complications including hematoma, pseudoaneurysm, arteriovenous fistula and arterial/venous thrombosis or stenosis. The safety end points were the vascular complications during the hospital stay, and the efficacy end points included device and procedure success. Results: The procedure success rate was 92.9% (39/42) and the device success rate was 88.1% (37/42). Major vascular complications occurred in 3 (7.1%) patients; 1 developed a massive hematoma >10 cm which was managed by blood transfusion and surgical reconstruction, and the other 2 developed pseudoaneurysm which was cured by ultrasound-guided thrombin injection or manual compression. Minor vascular complications occurred in 5 (11.9%) patients, including blood oozing in 2, hematoma <5 cm in 2 and severe pain in the remaining patient. Conclusion: CFA closure with the StarClose device was safe, feasible and effective in patients undergoing IABP support using 8-Fr sheath sizes.

Does the timing of treatment with intra-aortic balloon counterpulsation in cardiogenic shock due to ST-elevation myocardial infarction affect survival?

Intra-aortic balloon pump (IABP) counterpulsation and primary percutaneous coronary intervention (PCI) are standard treatment modalities in cardiogenic shock (CS) complicating acute myocardial infarction. The aim of this study was to investigate the impact of the timing of IABP treatment start in relation to PCI procedure. Data were obtained from the SCAAR registry (Swedish Coronary Angiography and Angioplasty Registry) about 139 consecutive patients with CS due to ST-elevation myocardial infarction (STEMI) who received IABP treatment. The patients were hospitalized at Sahlgrenska University Hospital, Gothenburg, during 2004-2008. The cohort was divided into the two groups: group (A) in whom IABP treatment started before start of PCI (n = 72) and group (B) in whom IABP treatment started after PCI treatment (n = 67). The primary endpoint was 30-day mortality. Propensity score (PS) adjusted Cox proportional hazards regression was used to analyze predictors of 30-day mortality. Mean age was 66.5 ± 12 and 28% were women. All patients have received IABP treatment 30 min before or 30 min after primary PCI. 63% had diabetes and 28% had hypertension. 16% were active tobacco smokers. The mortality rate at 30 days was 38%. IABP treatment commenced before or after PCI was not an independent predictor of mortality (P = 0.72). In this non-randomized trial the treatment with insertion of IABP before primary PCI in patients with CS due to STEMI is not associated with a more favorable outcome as compared with IABP started after primary PCI.

(765) - Mechanical Circulatory Support for Primary Graft Dysfunction Following Heart Transplantation: Risk Factors and Clinical Outcome

Primary graft dysfunction (PGD) following heart transplantation often necessitates institution of mechanical circulatory support (MCS). Mild to moderate PGD can be supported with intra-aortic balloon pump (IABP) counterpulsation, whereas severe PGD requires ventricular assist device (VAD) insertion. Our aim was to identify predictors of post-transplant MCS and its impact on clinical outcome.

Intra-aortic balloon pump (IABP) counterpulsation improves cerebral perfusion in patients with decreased left ventricular function

The current goal of treatment after acute ischemic stroke is the increase of cerebral blood flow (CBF) in ischemic brain tissue. Intra-aortic balloon pump (IABP) counterpulsation in the setting of cardiogenic shock is able to reduce left ventricular afterload and increase coronary blood flow. The effects of an IABP on CBF have not been sufficiently examined. We hypothesize that the use of an IABP especially enhances cerebral blood flow in patients with pre-existing heart failure. In this pilot study, 36 subjects were examined to investigate the effect of an IABP on middle cerebral artery (MCA) transcranial Doppler (TCD) flow velocity change and relative CBF augmentation by determining velocity time integral changes (ΔVTI) in a constant caliber of the MCA compared to a baseline measurement without an IABP. Subjects were divided into two groups according to their left ventricular ejection fraction (LVEF): Group 1 LVEF >30% and Group 2 LVEF ≤30%. Both groups showed an increase in CBF using an IABP. Patients with a LVEF ≤30% showed a significantly higher increase of ΔVTI in the MCA under IABP augmentation compared to patients with a LVEF >30% (20.9% ± 3.9% Group 2 vs.10.5% ± 2.2% Group 1, p<0,05). The mean arterial pressure (MAP) increased only marginally in both groups under IABP augmentation. IABP improves cerebral blood flow, particularly in patients with pre-existing heart failure and highly impaired LVEF. Hence, an IABP might be a treatment option to improve cerebral perfusion in selected patients with cerebral misperfusion and simultaneously existing severe heart failure.

Early ‘in-lab’ use of levosimendan in patients with cardiogenic shock unsuitable for intra-aortic balloon pump counterpulsation

Intra-aortic balloon pump counterpulsation is currently the most used mechanical assistance device for patients with cardiogenic shock due to acute myocardial infarction. However, a recently published meta-analysis and trial failed to confirm previous knowledge. We report the results of four patients with ST elevation myocardial infarction, complicated by cardiogenic shock unsuitable for intra-aortic balloon pump counterpulsation treated with early levosimendan infusion during primary percutaneous coronary intervention.

Correlates for mortality in patients presented with acute myocardial infarct complicated by cardiogenic shock

This study aimed to explore the correlates for mortality in patients treated with both primary percutaneous coronary intervention (PCI) and intra-aortic balloon pump counter-pulsation (IABP). Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with high mortality rates. From a cohort of patients with AMI, treated with both primary PCI and IABP and who met strict definitions for CS to identify correlates associated with mortality, the study compared patients who died in-hospital to those who survived to discharge. A cohort of 93 patients met the inclusion/exclusion criteria. Of them, 66.7% were male, and the average age was 64.96±13.06years. The overall in-hospital mortality rate for this cohort was 33%. The baseline characteristics were balanced save for older average age and left ventricular ejection fraction in those who died (p=0.049 and p=0.014, respectively). Insertion of IABP pre-PCI and cardiac arrest at the catheterization lab were more frequent in those who died (p=0.027 and p=0.008, respectively). The insertion of IABP pre-PCI, cardiac arrest at the cath lab, and lower ejection fraction were correlated with in-hospital mortality (ORs 2.68, 5.93, and 0.02, respectively). In the era of primary PCI and IABP as standard of care in AMI complicated by CS, patients with low EF, those who necessitate IABP insertion pre-PCI, and those who necessitate cardiopulmonary resuscitation during PCI are at higher risk for in-hospital mortality and should be considered for more robust hemodynamic support devices with an attempt to improve their prognosis.

Intraaortic balloon pump use in high-risk percutaneous coronary intervention

Despite the long-term availability and clinical usage of intraaortic balloon pump (IABP) counterpulsation, there is a paucity of randomized trial evidence for its use. Here, we will review the latest evidence for its usage in different clinical settings. There have been decades of nonrandomized and observational data available, but only in the last 3 years has there been availability of randomized evidence for IABP use in acute myocardial infarction (AMI) with cardiogenic shock, ST elevation acute coronary syndromes (STE-ACS) without shock and high-risk percutaneous coronary intervention (PCI) cohorts. To the surprise of many, despite the sound physiological benefits achieved by the use of IABP counterpulsation in these situations, all the recent trials did not achieve the primary endpoint, although there is a trend towards long-term benefit with its use. This may alter its elective use in practice and may lead to changes in current guidance and possibly increase the focus on other mechanical circulatory devices. Despite the neutral primary endpoints in these recent trials, there is a signal that a subset of the population may benefit by elective IABP use and get good haemodynamic support, thus suggesting, in our view, that further understanding and research are required to gain maximum physiological benefit from this device and to aid decision making for an individualized, patient-centred approach.

End-diastolic flow reversal limits the efficacy of pediatric intra-aortic balloon pump counterpulsation

Counterpulsation with an intra-aortic balloon pump (IABP) has not achieved the same success or clinical use in pediatric patients as in adults. In a pediatric animal model, IABP efficacy was investigated to determine whether IABP timing with a high-fidelity blood pressure signal may improve counterpulsation therapy versus a low-fidelity signal. In Yorkshire piglets (n=19; weight, 13.0 ± 0.5 kg) with coronary ligation-induced acute ischemic left ventricular failure, pediatric IABPs (5 or 7 mL) were placed in the descending thoracic aorta. Inflation and deflation were timed with traditional criteria from low-fidelity (fluid-filled) and high-fidelity (micromanometer) blood pressure signals during 1:1 support. Aortic, carotid, and coronary hemodynamics were measured with pressure and flow transducers. Myocardial oxygen consumption was calculated from coronary sinus and arterial blood samples. Left ventricular myocardial blood flow and end-organ blood flow were measured with microspheres. Despite significant suprasystolic diastolic augmentation and afterload reduction at heart rates of 105 ± 3 beats per minute, left ventricular myocardial blood flow, myocardial oxygen consumption, the myocardial oxygen supply/demand relationship, cardiac output, and end-organ blood flow did not change. Statistically significant end-diastolic coronary, carotid, and aortic flow reversal occurred with IABP deflation. Inflation and deflation timed with a high-fidelity versus low-fidelity signal did not attenuate systemic flow reversal or improve the myocardial oxygen supply/demand relationship. Systemic end-diastolic flow reversal limited counterpulsation efficacy in a pediatric model of acute left ventricular failure. Adjustment of IABP inflation and deflation timing with traditional criteria and a high-fidelity blood pressure waveform did not improve IABP efficacy or attenuate flow reversal. End-diastolic flow reversal may limit the efficacy of IABP counterpulsation therapy in pediatric patients with traditional timing criteria. Investigation of alternative deflation timing strategies is warranted.

Central venous oxygen saturation (ScVO2) facilitates the weaning of intra-aortic balloon pump in acute heart failure related to acute myocardial infarction

Intra-aortic balloon pump (IABP) counterpulsation can improve coronary blood flow by augmenting coronary diastolic blood pressure. IABP can also increase cardiac index by reducing left ventricular workload [1–3]. The role of IABP in cardiogenic shock related to acute myocardial infarction (AMI) is well established in current practice guidelines [4].

First Experience With Implantation of a Percutaneous Right Ventricular Impella Right Side Percutaneous Support Device as a Bridge to Recovery in Acute Right Ventricular Infarction Complicated by Cardiogenic Shock in the United States

We report the first implantation in the United States of a novel percutaneous right ventricular (RV) support device as a bridge to recovery in a patient with RV infarction with cardiogenic shock refractory to standard care. A 64-year-old man, with prior inferior wall myocardial infarction treated with percutaneous coronary intervention, presented with late drug-eluting stent thrombosis inferoposterior ST-segment–myocardial infarction complicated by cardiac arrest requiring defibrillation of ventricular tachycardia (Figure 1; Movie I and II in the online-only Data Supplement). Despite revascularization, fluid administration to a central venous pressure of 20 mm Hg, dobutamine and vasopressin infusions, and intra-aortic balloon pump counterpulsation, he remained in RV shock (cardiac index of 1.8 L/min per m2). With use of antiplatelet drugs, surgical cannulation for extracorporeal support was deemed an excessive risk. Figure 1. Acute inferoapical ST-elevation–myocardial infarction (STEMI) treated …

Early application of an intra-aortic balloon pump in patients with ST-segment elevation acute myocardial infarction scheduled for elective percutaneous coronary intervention

This study evaluated the effect of early application of intra-aortic balloon pump (IABP) counterpulsation in patients with ST-segment elevation acute myocardial infarction (STEMI), scheduled for elective percutaneous coronary intervention (PCI). Patients who had experienced STEMI for 12-72 h received (IABP group) or did not receive (control group) IABP counterpulsation for 3-5 days before PCI. One hundred patients were included. Frequencies of infarct-related artery thrombolysis in acute myocardial infarction (TIMI) flow rate classes 0, I and II in the IABP group (11.5, 1.9 and 7.7%, respectively) were significantly lower than in the control group (29.1, 14.6 and 22.9%, respectively) before PCI. After PCI, the frequency of TIMI class III flow rate in the IABP group (96.2%) was significantly higher than that in the control group (81.3%). Four weeks after PCI, the left ventricular ejection fraction (LVEF) was significantly higher, and the incidence of major cardiac events was significantly lower, in the IABP group compared with the control group. Early use of IABP counterpulsation in STEMI patients scheduled for PCI was effective, with a favourable safety profile. IABP counterpulsation reduced the incidence of major adverse cardiac events and improved LVEF. However, IABP devices must be used at an early stage, to obtain optimal results.

Intra-aortic balloon pump counterpulsation: are we optimizing the management of cardiogenic shock?

Intra-aortic balloon pump counterpulsation (IABPC) has been used in various forms for decades. The change in physiology brought about by their use is conceptually appealing in managing cardiogenic shock and mechanical complications of myocardial infarction. A common myth is that this method of managing acute cardiological emergencies is to be limited to the realms of this specialist field. However, as medical physicians an appreciation and understanding of this novel therapy is essential not only as a lifesaving measure but also as a bridging therapy to more definitive management in the acute medical setting. IABPC is a safe and under-utilized technique despite featuring in all major international guidelines (ESC and ACC) for the management of cardiogenic shock secondary to acute coronary syndromes. Without awareness of this intervention we may be suboptimally managing patients in the first instance. To improve awareness we examine the evidence supporting the use of the IABPC therapy and the contraindications to their use. Complications and advances in technology are also addressed.

Left Ventricular Support Systems for High-Risk Percutaneous Coronary Interventions

High-risk percutaneous coronary interventions (PCI) are becoming more prevalent as the ability to perform complex coronary interventions continues to improve. Patients for whom high-risk interventions are considered generally have severe diffuse coronary artery disease, a single last patent conduit, or significant left main disease with large territories of myocardial ischemia. In addition, these patients also typically have reduced left ventricular function (ejection fraction <25%–35%) with comorbidities that make them high risk for standard coronary artery bypass grafting. Thus, PCI is increasingly used as a viable alternative for coronary revascularization, but it too is associated with a high degree of morbidity and mortality. Article see p 207 Coronary ischemia can transiently worsen during PCI through repeated balloon inflations, stent manipulations, and contrast injections that result in a negative inotropic effect.1 In patients with left ventricular dysfunction and large territories of ischemia who have little reserve, this can lead to reductions in blood pressure that make it hard to complete the revascularization. Hemodynamic support during the conduct of the PCI, such as that provided by intra-aortic balloon pump (IABP) counterpulsation or Impella, may therefore maintain perfusion pressure throughout the procedure to reduce the risk associated with these complex interventions. Kahn and colleagues reported the first use of intra-aortic balloon pumps to support high-risk PCI in 1990 among 28 patients with severe LV dysfunction undergoing PCI for 3-vessel or left main coronary artery disease.2 This study established that IABP support in this setting was safe and allowed the PCI to be completed without untoward risk. IABP use for this indication has continued to grow since that time and now is one of the more common reasons for IABP use in the cardiac catheterization laboratory, reflective of the growing number of high-risk PCIs being performed by interventional cardiologists.3 In an analysis …

Does intra-aortic balloon support for myocardial infarction with cardiogenic shock improve outcome?

Expanded abstractCitationThiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm M, Ebelt H, Schneider S, Schuler G, Werdan K; IABP-SHOCK II Trial Investigators: Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012, 367:1287-1296.BackgroundIn the current international guidelines, intra-aortic balloon pump (IABP) counterpulsation is considered a class I treatment for acute myocardial infarction complicated by cardiogenic shock. However, evidence is based mainly on registry data, and there is a paucity of randomized clinical trials.MethodsObjectiveTo test the hypothesis that IABP counterpulsation, as compared with the best available medical therapy alone, results in a reduction in mortality among patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization is planned.DesignRandomized, prospective, open-label, multicenter trial.SettingThirty-seven centers in Germany.SubjectsAll adults had acute myocardial infarction complicated by cardiogenic shock and were expected to undergo early revascularization (by means of percutaneous coronary intervention or bypass surgery).InterventionAfter enrollment, 600 patients were randomly assigned to intra-aortic balloon counterpulsation (IABP group, 301 patients) or no IABP counterpulsation (control group, 299 patients).OutcomesThe primary efficacy endpoint is 30-day all-cause mortality.ResultsAt 30 days, 119 patients in the IABP group (39.7%) and 123 patients in the control group (41.3%) had died (relative risk with IABP, 0.96; 95% confidence interval, 0.79 to 1.17; P = 0.69). There were no significant differences in secondary endpoints or in process-of-care measures, including the time to hemodynamic stabilization, the length of stay in the intensive care unit, serum lactate levels, the dose and duration of catecholamine therapy, and renal function.ConclusionsThe use of IABP counterpulsation did not significantly reduce 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock for whom an early revascularization strategy was planned.

Vascular Complications of the Intra-aortic Balloon Pump in Patients Undergoing Open Heart Surgery: 10 Years' Experience

The most encountered complications with intra-aortic balloon pump (IABP) use are seen within the vascular system. The purpose of our study is to evaluate vascular complications of the sheathless IABP in patients undergoing open heart surgery. Between January 2002 and December 2011, a total of 148 patients undergoing open heart surgery and needed IABP support were included in the study. All vascular complications related with IABP were recorded. Mean age of the patients was 64.4 ± 9.4 years. Total 104 (70.2%) were male and 44 (29.8%) were female. Total number of patients who had ischemic complications of the extremity was 13 (8.7%). The most used surgical treatment was embolectomy in five patients. Only one patient required an iliofemoral bypass. Above the knee amputation was performed in one patient. No balloon-related mortality occurred. Incidence of vascular complications in IABP counterpulsation is still a problem despite improvements in catheter design and techniques. The presence of peripheral arterial disease and diabetes mellitus is important risk factors for ischemic complications.