Intra-aortic Balloon Counterpulsation Research Articles

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.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2012

Cardiothoracic and vascular critical care has emerged as a subspecialty due to procedural breakthroughs, an aging population, and a multidisciplinary collaboration. This subspecialty now has a dedicated professional society, recently published guidelines, and plans for standardized certification. This paradigm shift represents a major collaboration opportunity for our specialty. The rise of evidence-based perioperative practice has produced a culture of large trials in our specialty to search for solutions to the challenging outcome questions. Besides the growth in the development of evidence, the consensus conference format and postpublication peer review have both emerged as effective processes for identifying the most relevant high-quality evidence. The quest for best perioperative practice has highlighted the importance of teamwork at all phases of care with respect to transitions in care, blood component transfusion, and research misconduct. The emergence of ultrasound as a standard for central vascular access also has been emphasized in recent multisociety guidelines. There also has been a paradigm shift in the management of patients with coronary artery disease. Recent guidelines have emphasized the roles of the cardiac anesthesiologist and the interventional cardiologist as part of the heart team approach. Major recent trials in comparative effectiveness have challenged the advantages of percutaneous coronary intervention, off-pump coronary artery bypass surgery, and intra-aortic balloon counterpulsation. The year 2012 has witnessed the emergence of new paradigms of care in our specialty with the emphasis on teamwork, safety, and quality. These processes will further improve perioperative outcome.

The efficacy of different types of heparin in intra-aortic balloon counterpulsation

Objective To explore the efficacy of low molecular weight heparin versus that of unfractionated heparin in intra-aortic balloon counterpulsation.Methods 28 patients who received low-molecular-weight heparin during intra-aortic balloon counterpulsation were assigned to study group,while 30 patients who received unfractionated heparin were allocated to control group.The efficacy was compared between the two groups.Results The immediate improvement rate of disease severity and the mortality rate within 30 days did not differ significantly between the two groups [(67.86％ vs.56.67％) and (10.71％ vs.16.67％),(P＞ 0.05)].The incidence rate of complications including bleeding and hematoma was significantly lower in the study group than in the control group (7.14％ vs.30％),with a relative risk ratio of 4.200.There were no significant differences in the incidence of plug formation in balloon center and that of lower limb ischemia between the two groups (3.57％ vs.16.67％).The mean platelet count was lower in the control group than in the study group [(158.5 ± 82.9) × 109/L vs.(231.3 ± 45.2) × 109/L].Conclusions During intra-aortic balloon counterpulsation,as compared with unfractionated heparin,although low-molecular-weight heparin has no marked effect on disease severity and rate of mortality,it significantly lowers the rate of bleeding and has less impact on platelet.Low-molecular-weight heparin can replace unfractionated heparin as an anticoagulant during intra-aortic balloon counterpulsation. Key words: Aortic balloon pump surgery; Unfractionated heparin; Low-molecular-weight heparin; Efficacy

Intra-aortic balloon counterpulsationを併用した頚動脈ステント留置術

【目的】重症心疾患合併頚動脈狭窄症に対して頚動脈ステント留置術（carotid artery stenting；CAS）周術期の徐脈，低血圧による心筋虚血，血行動態破綻の予防目的でIntra-aortic balloon counterpulsation（IABP）併用CASを行った．【結果】（症例1）症候性頚動脈狭窄症，重度大動脈弁狭窄症（aortic valve stenosis；AS）合併，弁置換術前．（症例2）無症候性頚動脈狭窄症，3枝病変狭心症合併，バイパス術前．IABPカテーテル（8Fr）は大腿動脈から誘導，合併症なくCASを施行できた．【結論】IABP併用CASは心合併症予防に有用でAS等重症心疾患合併症例にも行える可能性がある．

The Janus of Oxidative Stress Signaling in Different Pathophysiological Conditions

The Janus of Oxidative Stress Signaling in Different Pathophysiological Conditions

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.

IABP before cardiac surgery: clinical benefit compared to intraoperative implantation

The aim of this study was to determine whether preoperative compared to intraoperative intra-aortic balloon counterpulsation (IABP) is advantageous regarding 30-day and 2-year survival in high-risk patients (acute myocardial infarction, severely impaired left ventricular ejection fraction (LVEF), low output syndrome) undergoing coronary surgery. In the years 2004 to 2008, 156 consecutive patients undergoing coronary surgery with IABP support (119 preoperative, 37 intraoperative IABP) were observed. Applying Fisher's exact test, as well as Wilcoxon and median tests, possible group differences were evaluated. After univariate analysis, models of logistic regression and Cox-regression were built. Preoperative hemodynamic state and risk profile of the two patient groups were comparable: patients with preoperative IABP showed a similar level of urgency (21.9% vs. 18.9% emergencies), cardiogenic shock (8.4% vs. 10.8%), inotropes (8.4% vs. 8.1%), impaired LVEF (30.3% vs. 29.7%) and ventilation (5.9% vs. 5.4%) compared to patients with intraoperative IABP. Nevertheless, patients with intraoperative IABP demonstrated a significantly higher 30-day mortality rate (37.8% vs. 5.9%) and 2-year mortality rate (54.0% vs. 18.1%) compared to patients with preoperative IABP. Logistic regression revealed that patients with intraoperative IABP have a 16-times higher 30-day mortality rate after coronary surgery (OR: 16.386, 95% CI: 4.858-55.266) than patients with preoperative IABP. Two-year mortality (OR: 9.317, 95% CI: 3.430 to 25.311) and survival time were significantly better in patients with preoperative IABP therapy. Considering the significant benefit for patients with preoperative compared to intraoperative IABP and the absence of vascular problems after IABP insertion, the results of this study indicate a more liberal indication for IABP in high-risk patients before coronary bypass surgery.

Intraaortic balloon counterpulsation did not reduce mortality in acute MI with cardiogenic shock

Source Citation Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367:1287-96. 22920912

Percutaneous left ventricular support in cardiogenic shock and severe aortic regurgitation

Severe aortic regurgitation (AR) is a well-established contraindication to intra-aortic balloon counterpulsation therapy. We report two cases of medically refractory cardiogenic shock in patients with severe AR who were successfully bridged to surgical left ventricular assist device implantation by percutaneous left atrial to femoral artery mechanical bypass. Further investigation into the clinical utility of percutaneous mechanical support in the setting of AR and shock is required.

A Randomized Controlled Trial of Prophylactic Intra-aortic Balloon Counterpulsation in High-Risk Aneurysmal Subarachnoid Hemorrhage

To assess whether prophylactic postoperative intraaortic balloon counterpulsation (IABC) reduces the risk of poor outcome because of vasospasm following aneurysmal subarachnoid haemorrhage relative to conventional hypervolemic therapy (HT). This was a single-center, parallel group randomized controlled trial. Patients suffering a subarachnoid hemorrhage at high risk of vasospasm were eligible. Patients were randomly allocated to receive prophylactic IABC (n=35) or HT (n=36). The primary end point was Glasgow Outcome and SF-36 scores assessed at 6 months by a blinded and independent observer and analyzed by intention to treat. Secondary analysis of physiological parameters was by treatment performed. Twenty-seven patients in each arm had a good outcome (P=0.55). There was no statistical difference in mean SF-36 score (t=0.39, P=0.70). There were no long-term complications secondary to IABC. There were no differences in preload (pulmonary artery wedge pressure, P=0.97) or afterload (mean arterial pressure, P=0.97). IABC was associated with a lower cardiac output (P=0.002) and higher systemic vascular resistance (P=0.005), although for both groups mean cardiac output was >6 L/min. Cerebral blood flow was not different between groups: HT=41.5 (SD 7.2), IABP=44.9 (SD 8.6) mL/100 g/min (P=0.14). In this study, prophylactic IABC did not improve perfusion indices or confer any clinical benefit following subarachnoid haemorrhage in patients with normal cardiac function. The study was small, however, and cannot be extrapolated to patients with cardiac failure and medically refractory symptomatic cerebral vasospasm. Clinical Trial Registration- This trial was not registered because enrolment began prior to July 1, 2005.

The impact of intra-aortic balloon counter-pulsation on in-hospital mortality in patients presenting with anterior ST-elevation myocardial infarction without cardiogenic shock

This study aimed to determine whether the elective insertion of an intra-aortic balloon counter pulsation (IABP) device at the time of myocardial revascularization in patients presenting with an acute anterior ST-elevation myocardial infarction (STEMI) without cardiogenic shock has any impact on the in-hospital rate of cardiac mortality. The role of IABP in patients presenting with an acute MI without cardiogenic shock remains ill defined. The present study comprised 605 consecutive patients who underwent primary percutaneous coronary intervention for an anterior STEMI without cardiogenic shock. Patients who received IABP at the time of their coronary revascularization (n=105) were compared to those who had not (n=500). Patients with stable angina, unstable angina, non-STEMI, non-anterior STEMI, and cardiogenic shock were excluded. The two cohorts were well matched for the conventional risk factors for coronary artery disease. Although the left ventricular ejection fraction was significantly lower in the patients who received IABP (0.32±0.11 vs. 0.39±0.12; P<0.001), the two cohorts were well matched for history of MI, coronary revascularization, and chronic renal impairment. Following propensity scoring, the in-hospital rate of cardiac death was similar between the two cohorts (5.6% vs. 0%; P=.12) as was the rate of vascular complications. Major bleeding was significantly greater in the IABP cohort (10.0% vs. 0%; P=.01) leading to a greater transfusion requirement (14.9% vs. 2.9%; P=.01). The adjunctive use of an IABP in patients presenting with an acute anterior STEMI without cardiogenic shock may not be associated with an in-hospital mortality benefit.

Cardiac transplantation for spontaneous coronary artery dissection

We report a 49-year old female who presented with ST elevation myocardial infarction, in whom thrombolysis and coronary angioplasty failed to perfuse the myocardium. She was unsuitable for emergency coronary artery bypass grafting surgery due to the interval elapsed between the myocardial infarction, thrombolysis and large infracted myocardium. Ventricular-assisted device support for a bridge to recovery or transplantation is a widely accepted treatment modality; however, in this case, it was unadvisable due to the extent of the infarcted myocardium and the risk of suturing outflow ports into the infracted myocardium. The patient's condition was stabilized with cardiac inotropic support, intra-aortic balloon counter pulsation and extracorporeal membrane oxygenation as a last resort until a heart became available for transplantation. The patient received successful orthotopic heart transplantation 4 days after her initial presentation and her postoperative recovery was uneventful.

Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock

BackgroundIn current international guidelines, intraaortic balloon counterpulsation is considered to be a class I treatment for cardiogenic shock complicating acute myocardial infarction. However, evidence is based mainly on registry data, and there is a paucity of randomized clinical trials.MethodsIn this randomized, prospective, open-label, multicenter trial, we randomly assigned 600 patients with cardiogenic shock complicating acute myocardial infarction to intraaortic balloon counterpulsation (IABP group, 301 patients) or no intraaortic balloon counterpulsation (control group, 299 patients). All patients were expected to undergo early revascularization (by means of percutaneous coronary intervention or bypass surgery) and to receive the best available medical therapy. The primary efficacy end point was 30-day all-cause mortality. Safety assessments included major bleeding, peripheral ischemic complications, sepsis, and stroke.ResultsA total of 300 patients in the IABP group and 298 in the control group were included in the analysis of the primary end point. At 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 end points 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. The IABP group and the control group did not differ significantly with respect to the rates of major bleeding (3.3% and 4.4%, respectively; P=0.51), peripheral ischemic complications (4.3% and 3.4%, P=0.53), sepsis (15.7% and 20.5%, P=0.15), and stroke (0.7% and 1.7%, P=0.28).ConclusionsThe use of intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned. (Funded by the German Research Foundation and others; IABP-SHOCK II ClinicalTrials.gov number, NCT00491036.)

Choc cardiogénique ischémique. Où en est-on en 2012 ?

With a stable frequency (about 5% of acute coronary syndromes) and a mortality of nearly 45%, cardiogenic shock (CS), especially when it occurs in the immediate waning of myocardial infarction, still represents a therapeutic challenge. In this review, will be detailed the actual epidemiologic data of CS, its physiopathology and the different modalities of treatments available to the interventional cardiologist, especially the coronary revascularisation and the percutaneous left ventricular assistance, whether by intra-aortic balloon counterpulsation or by more complex systems.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Intra-aortic balloon counterpulsation in acute coronary syndromes: the thin line between use and over-use. Where is the evidence? Intra-aortic balloon counterpulsation is probably over-used

Intra-aortic balloon counterpulsation in acute coronary syndromes: the thin line between use and over-use. Where is the evidence? Intra-aortic balloon counterpulsation is probably over-used

Acute ST-elevation myocardial infarction

Acute ST-elevation myocardial infarction (STEMI) is a major cause of morbidity, mortality, and disability. This review summarizes recent advances in the treatment of patients with STEMI. The best prehospital and interhospital transfer strategy for patients with STEMI is rapid transport to a percutaneous coronary intervention (PCI) center by Emergency Medical Services, with prehospital diagnosis and activation of the cardiac catheterization laboratory. Coronary angiography is now recommended for all patients with STEMI. Advances in adjunctive pharmacological and device therapy have improved primary PCI results. Thrombus aspiration, drug-eluting stents, systemic hypothermia for survivors of cardiac arrest with anoxic encephalopathy, and stem cells as reparative therapy have undergone recent evaluation. Primary PCI with stent implantation as soon as possible is the best treatment strategy for patients with STEMI. Aspirin, bivalirudin, and either prasugrel or ticagrelor are the best antithrombotic agents to support primary PCI. Thrombus aspiration and intra-aortic balloon counterpulsation are important device adjuncts. Systemic hypothermia appears to be an important advance for survivors of cardiac arrest with anoxic encephalopathy, but the benefits of stem cell therapy have yet to be proven.

TCT-67 Impact of Hemodynamic Support With Impella vs Intraaortic Balloon Counterpulsation on Prognostically Important Ischemic Endpoints: Results from the PROTECT-II Trial

Improved hemodynamic support may facilitate high risk PCI. The appropriate definition of peri-procedural cardiac enzyme elevation to define a clinically relevant myocardial infarction (MI) is controversial, although the advent of new Q-waves or a CK-MB elevation >8x normal have been previously

CORONARY ANGIOGRAPHY LEAD TO LEFT MAIN CORONARY ARTERY DISSECTION AND OCCLUSION: 1 CASE DEAD

Objectives1. Clinical Data: Patients, female, 70 years old, farmers, because of repeated chest tightness companion with obstruction in pars laryngea pharyngis half a months, was admitted to hospital on November...