Intra-aortic Balloon Pump Counterpulsation Research Articles

P80: Adding Intra-Aortic Balloon Pump Counter-Pulsation To Vasodilator Therapy Results In Better Organ Perfusion In Patients With Biventricular Heart Failure Awaiting A Heart Transplant

Background: Significant right ventricular dysfunction with elevated central venous pressure is associated with poor survival in heart failure patients with reduced ejection fraction (HFrEF). Heart transplant is often the only option for this group of patients, as they are not candidates for left ventricular assist device therapy. Medical management of HFrEF involves lowering the systemic afterload with vasodilators. While this therapy is very effective in isolated left ventricular dysfunction, in patients with biventricular dysfunction and high venous pressure, vasodilation can lead to low organ perfusion pressure, resulting in organ dysfunction. Organ perfusion pressure is calculated as the difference between mean arterial pressure and central venous pressure. We hypothesized that combining intra-aortic balloon pump (IABP) counter-pulsation with vasodilator therapy might be a good clinical option for stabilizing these patients while awaiting a heart transplant. Methods: To understand the hemodynamics of vasodilator and IABP therapy in biventricular heart failure, we used a closed-loop multiscale model of the entire cardiovascular system, including a one-dimensional model of the arterial tree coupled with a lumped model of the heart and IABP counter-pulsation. In addition, a baroreceptor model was also used to capture the physiological changes secondary to ventricular dysfunction realistically. Results: Our mathematical model accurately captures the features of the aortic pressure waveform with IABP support (Figure 1) and the hemodynamic consequences of the onset of right ventricular dysfunction (Table 1). Biventricular dysfunction leads to lower cardiac output and organ perfusion pressure when compared with isolated left ventricular dysfunction. Vasodilation during biventricular dysfunction increases the cardiac output but reduces the organ perfusion pressure further. IABP counter-pulsation increases cardiac output along with higher mean arterial pressure and hence higher organ perfusion pressure. The best results are seen when vasodilators are used in conjunction with IABP, where a “sweet spot” of maximal increase in cardiac output with the best possible organ perfusion pressure is obtained, and this combined additive effect of IABP counter-pulsation and vasodilation is also reflected across the renal vasculature (Table 1). Conclusion: Vasodilation with high venous pressure can lead to low organ perfusion pressure and consequent organ dysfunction. Fine-tuning IABP counter-pulsation and vasodilator seems to confer a substantial hemodynamic benefit in this setting.Figure 1. Simulated aortic pressure waveform with IABP support

Prospective Phenotyping of Right Ventricle Function Following Intra-Aortic Balloon Pump Counterpulsation in Left Ventricular Assist Device Candidates: Outcomes and Predictors of Response.

Intra-aortic balloon pump (IABP) may be applied to optimize advanced heart failure (AHF) patients and improve right ventricular (RV) function before left ventricular assist device (LVAD) implantation. We aimed to evaluate the outcome of this intervention and define RV response predictors. Decompensated AHF patients, not eligible for LVAD because of poor RV function, who required IABP for stabilization were enrolled. Echocardiography and invasive hemodynamics were serially applied to determine fulfillment of prespecified "LVAD eligibility RV function" criteria (right atrium pressure [RA] <12 mm Hg, pulmonary artery pulsatility index [PAPi] >2.00, RA/pulmonary capillary wedge pressure [PCWP] <0.67, RV strain <-14.0%). Right ventricular-free wall tissue was harvested to assess interstitial fibrosis. Eighteen patients (12 male), aged 38 ± 14 years were supported with IABP for 55 ± 51 (3-180) days. In 11 (61.1%), RV improved and fulfilled the prespecified criteria, while seven (38.9%) showed no substantial improvement. Histopathology revealed an inverse correlation between RV interstitial fibrosis and functional benefit following IABP: interstitial fibrosis correlated with post-IABP RA ( r = 0.63, p = 0.037), RA/PCWP ( r = 0.87, p = 0.001), PAPi ( r = -0.83, p = 0.003). Conclusively, IABP improves RV function in certain AHF patients facilitating successful LVAD implantation. Right ventricular interstitial fibrosis quantification may be applied to predict response and guide preoperative patient selection and optimization. http://links.lww.com/ASAIO/A995.

Analysis of results from intra-aortic balloon pump counterpulsation in patients with myocardial infarction and cardiogenic shock

Aim. To build a clinical and instrumental profile of patients with myocardial infarction (MI) complicated by the development of cardiogenic shock (CS) who underwent intra-aortic balloon pump (IABP) counterpulsation and evaluate the results of this treatment.Material and Methods. The single-center observational registry study comprised patients with admitting diagnosis of MI complicated by CS who were admitted to Cardiology Research Institute of Tomsk NIMC from 01.01.2020 to 12.31.2021. All patients received emergency IABP at admission, and reperfusion of infarct-related artery was achieved. According to these criteria, a total of 23 patients were included in the analysis.Results. The average age of patients was 79 years. There were comparable numbers of men and women in study group. Vast majority of patients (78.2%) had postinfarction cardiosclerosis; 86.9% of patients had hypertension; third of patients had diabetes mellitus; and almost half of patients were obese. Most of these patients (73.9%) had MI with ST segment elevation; the rest of patients had MI without ST segment elevation. 60.9% of patients had anterior wall MI, and the rest of patients had inferior wall MI. The pain-to-door time was 223 minutes on average. Thrombolysis was performed in 9 cases (39%) at the prehospital stage with an efficiency of 55%. The majority of patients (n = 22) underwent coronary stenting of infarct-related artery. The duration of IABP was 52.5 hours an average, and the mortality rate was 69.5%. All fatal outcomes occurred as a result of CS progression. There were no statistically significant differences in the main clinical and anamnestic characteristics between the groups with the administration of IABP before and after PCI, although the patients in the group of IABP before PCI were younger, had a lower level of troponin at admission, more often achieved coronary reperfusion TIMI-2-3 at PCI, and had lower mortality.Conclusion. The frequency of IABP administration to patients with MI and CS in our department was 8%. The mortality rate among patients who underwent IABP insertion reached 69.5%, which was not lower than the corresponding rate in the general group of CS (55%). The combination of IABP installation before PCI in the presence of achieved coronary reperfusion (spontaneous or due to thrombolysis) was associated with a tendency to decrease in mortality compared with the installation of IABP after PCI.

Veno-Arterial Extracorporeal Membrane Oxygenation in Elective High-Risk Percutaneous Coronary Interventions.

BackgroundThe safety and feasibility of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as mechanical circulatory support in high-risk percutaneous coronary intervention (HR-PCI) remain unclear.MethodsThis retrospective study included patients with complex and high-risk coronary artery disease who underwent elective PCI with VA-ECMO support pre-operatively during March 2019–December 2020. Rates of VA-ECMO-related complications, complications during PCI, death, myocardial infarction, and stroke during hospitalisation and 1-year post-operatively were analysed.ResultsOverall, 36 patients (average age: 63.6 ± 8.9 years) underwent PCI. The average duration of VA-ECMO support was 12.5 (range, 3.0–26.3) h. Intra-aortic balloon pump counterpulsation was used in 44.4% of patients. The SYNTAX score was 34.6 ± 8.4 pre-operatively and 10.8 ± 8.8 post-operatively (P < 0.001). Intraoperative complications included pericardial tamponade (N = 2, 5.6%), acute left-sided heart failure (N = 1, 2.8%), malignant arrhythmia requiring electrocardioversion (N = 2, 5.6%), and no deaths. Blood haemoglobin levels before PCI and 24 h after VA-ECMO withdrawal were 145.4 ± 20.2 g/L and 105.7 ± 21.7 g/L, respectively (P < 0.001). Outcomes during hospitalisation included death (N = 1, 2.8%), stroke (N = 1, 2.8%), lower limb ischaemia (N = 2, 5.6%), lower limb deep venous thrombosis (N = 1, 2.8%), cannulation site haematoma (N = 2, 5.6%), acute renal injury (N = 2, 5.6%), bacteraemia (N = 2, 5.6%), bleeding requiring blood transfusion (N = 5, 13.9%), and no recurrent myocardial infarctions. Within 1 year post-operatively, two patients (5.6%) were hospitalised for heart failure.ConclusionsVeno-arterial extracorporeal membrane oxygenation mechanical circulation support during HR-PCI is a safe and feasible strategy for achieving revascularisation in complex and high-risk coronary artery lesions. VA-ECMO-related complications require special attention.

Coincidence of Events Causing Paradoxical Hypotension in a Patient with an Intra-Aortic Balloon Pump.

The left ventricular outflow tract is a region of the left ventricle that lies between the anterior leaflet of the mitral valve and the ventricular septum. Dynamic left ventricular outflow tract obstruction (LVOTO) has classically been observed in patients with hypertrophic obstructive cardiomyopathy (HOCM) where it occurs secondary to asymmetric septal hypertrophy and systolic anterior motion (SAM) of the mitral valve. However, there are some instances that lead to hypercontractility of the myocardium, and with a combination of other physiological conditions, result in SAM of a mitral valve leaflet, leading to LVOTO in the absence of phenotype.We present such a case of an acute inferolateral wall myocardial infarction that was complicated by cardiogenic shock, requiring an intra-aortic balloon pump (IABP) and inotropic support which paradoxically provoked LVOTO. A reduction in IABP counterpulsation from 1:1 to 1:3 and the addition of intravenous fluids and a beta blocker resulted in significant improvement in blood pressure with rapid tapering of pressors.Inotropes and IABP, although helpful in cardiogenic shock, have the potential to induce or worsen the LVOTO, which can lead to a vicious cycle of worsening hypotension and increasing adrenergic drive that further deteriorates myocardial viability. Timely diagnosis with an echocardiogram and the withdrawal of inotropic and IABP support has the potential to improve haemodynamics and, thereby, outcome.LEARNING POINTSDynamic left ventricular outflow tract obstruction (LVOTO) should be one of the differentials in patients with cardiogenic shock, especially if it is refractory in the setting of an intra-aortic balloon pump.The diagnosis of LVOTO by echocardiography should result in immediate implementation of therapy to eliminate the factors that can potentially intensify the obstruction.

Intra-aortic Balloon Pump May Attenuate Adverse Hemodynamic Effects of Negative Intrathoracic Pressure in Cardiogenic Shock

High negative intrathoracic pressure (NIP), as occurs during obstructive sleep apnea or hiccups, results in adverse hemodynamic consequences, specifically a decrease in left ventricle (LV) performance. These untoward effects can potentially be catastrophic in the case of an already compromised LV in cardiogenic shock. The interplay of intra-aortic balloon pump counter pulsation during abrupt high NIP in cardiogenic shock is described.

Intra-aortic balloon pump counterpulsation: technical function, management, and clinical indications.

Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin Address Correspondence to: Laura S. González, MD, Department of Anesthesiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226. E-mail: [email protected]

Utilization and outcomes of postcardiotomy mechanical circulatory support.

This study evaluated the utilization and outcomes of postcardiotomy mechanical circulatory support (MCS). This was a retrospective, single institution analysis of adult cardiac surgery cases that required de novo MCS following surgery from 2011 to 2018. Patients that were bridged with MCS to surgery were excluded. The primary outcomes were early operative mortality and longitudinal survival. Secondary outcomes included postoperative complications, and 5-year all-cause readmission. Five hundred and thirty-three patients required de novo postcardiotomy MCS, with the most commonly performed procedure being isolated coronary artery bypass grafting (29.8%). Median cardiopulmonary bypass and cross-clamp times were 185 (IQR 123-260) minand 122 (IQR 81-179) min, respectively. A total of 442 (82.9%) of patients were supported with intra-aortic balloon pump counterpulsation, 23 (4.3%) with an Impella device, and 115 (21.6%) with extracorporeal membrane oxygenation. Three (0.6%) patients had an unplanned ventricular assist device placed. Operative mortality was 29.8%. Longitudinal survival was 56.1% and 43.0% at 1and 5 years, respectively. Survival was lowest in those supported with ECMO and highest with those supported with an Impella (p < 0.001). Freedom from readmission was 61.4% at 5 years. Postoperative ECMO was an independent predictor of mortality (HR 5.1, 95% CI 2.0-12.9, p < 0.001), but none of the MCS types predicted long-term hospital readmission after risk adjustment. Postcardiotomy MCS is associated with high operative mortality. Even patients that survive to discharge have compromised longitudinal survival, with nearly only half surviving to 1 year. Close follow-up and early referral to advanced heart failure specialists may be prudent in improving these outcomes.

Fondaparinux During Intra-Aortic Balloon Pump Counterpulsation in Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention

Although anticoagulation with unfractionated heparin (UFH) is commonly used during intra-aortic balloon pump (IABP) counterpulsation to prevent thromboembolic events, no data or guidelines exist to support this strategy, especially in the setting of acute myocardial infarction (AMI). This study sought to compare the short-term outcome of UFH vs fondaparinux in AMI patients who underwent successful percutaneous coronary intervention (PCI) and IABP insertion. The anticoagulation therapy of revascularised AMI patients who received IABP counterpulsation and admitted to a tertiary hospital in the last decade was retrospectively evaluated. The primary outcome was the occurrence of all-cause mortality, stroke or transient ischaemic attack, reinfarction, unplanned revascularisation, major or minor limb ischaemia, and any bleeding at 1 month. Propensity score matching was performed to compare the primary outcome between UFH and fondaparinux. Of 1,355 AMI survivors at 2 days after hospital admission and who underwent successful PCI, an IABP was inserted in 197 (14.5%): 72 (36.5%) were treated with UFH and 125 (63.5%) with fondaparinux (2.5 mg o.d.). At clinical follow-up, completed in 98.5% of cases, the incidence of the primary outcome was 22.5% in UFH and 5.7% in fondaparinux groups (p=0.0009). More than two-thirds of the events included in the primary outcome were related to early bleeding complications. In the matched cohort of 62 patients, the primary outcome occurred in 14 (45.2%) patients in the UFH and two (6.5%) in the fondaparinux group (p=0.01). This study suggested that fondaparinux is safer, by reducing early bleeding complications at one month, than UFH in the management of IABP.

Impact of mechanical circulatory support on donor heart allocation: past, present, and future.

The United Network for Organ Sharing (UNOS) recently revised its heart allocation policy to address numerous shortcomings of the previous system. Implemented in 2018, the changes sought to reduce waiting list mortality, clearly define urgency status based on objective physiologic variables, decrease exemption requests, and introduce geographic modifications to ensure organ distribution favors the highest urgency candidates. In large part, UNOS policy revisions were driven by the growing use of continuous flow left ventricular assist devices (CF-LVADs) and the relevant device complications that led to an unacceptably high number of status exemptions. The new 6-tiered system assigns a comparatively lower urgency status to patients supported on CF-LVADs and higher urgency to patients supported on short-term mechanical circulatory assist (MCA) such as extracorporeal membrane oxygenation (ECMO) and intraaortic balloon pump (IABP) counterpulsation. LVAD use as bridge to transplant (BTT) therapy increased steadily throughout the preceding decade due to technological improvements and increased physician familiarity, but the recent policy changes introduce incentives for physicians to withhold this life-saving therapy in order to achieve higher urgency status for their patients. This paper will explore the technological evolution of MCA and the pertinent clinical trials that have led to their FDA approval as BTT and destination therapy. A review of the inception and development of the donor allocation system will be provided before examining available post-policy outcome data. Finally, we will highlight successes and shortcomings of the implemented changes before commenting on areas to potentially expand upon the existing policy.

Prognostic Impact of Early Induction of Intra-Aortic Balloon Pump Counterpulsation in High-Risk Patients With Acute Heart Failure

BackgroundIntra-aortic balloon pumping (IABP) counterpulsation provides potent supports on hemodynamic status of patients with cardiogenic shock. However, only limited numbers of patients with acute heart failure (AHF) under collapsed hemodynamic status received such benefit of IABP. We aimed to evaluate the impact of the timing of IABP induction on clinical prognosis in AHF patients at very high risk. MethodsOf 404 consecutive AHF patients, 57 patients both with left ventricular ejection fraction (LVEF) <35% and systolic blood pressure on admission <100 mmHg were ultimately enrolled in this observational study. They were divided into 3 groups depending on IABP use; Early-IABP group (induction at ≤3 days after admission, n = 17), Late-IABP group (>3 days, n = 15) and No-IABP group (n = 25). The primary endpoint was a composite of in-hospital cardiovascular (CV) death and ventricular assisted device implantation. ResultsThis high-risk population was typically mid-age (60 years-old), 61% male, and 75% with chronic kidney disease, and its average LVEF was 24.7%. Clinical profiles on admission were comparable among 3 subgroups, except prehospital prescription rate of loop diuretics. During hospital stay, intravenous inotropes were significantly more frequently administered in the Late-IABP group than other 2 groups. The primary endpoint was developed in 17.6% of patients in the Early-IABP group, which was significantly lower than that in the Late-IABP group (53.3%, p = 0.034) and was comparable to the No-IABP group (40.0%, p = 0.12). ConclusionsEarly induction of IABP is one of the therapeutic options for improvement of in-hospital prognosis in AHF patients at very high risk.

Balloon Pump Counterpulsation Part II: Perioperative Hemodynamic Support and New Directions.

Intraaortic balloon pump (IABP) counterpulsation, introduced more than 50 years ago, remains the most commonly utilized mechanical circulatory support device for patients with cardiogenic shock and myocardial ischemia, despite lack of definitive proof regarding its outcome in these patients. Part I of this review focused on the history of counterpulsation, physiologic principles, technical considerations, and evidence for its use in cardiogenic shock; Part II will discuss periprocedural uses for IABP counterpulsation and review advances in technology, including the emergence of alternative mechanical circulatory support devices that have influenced IABP utilization.

Intraaortic Balloon Pump Counterpulsation, Part I: History, Technical Aspects, Physiologic Effects, Contraindications, Medical Applications/Outcomes.

Intraaortic balloon pump counterpulsation is the most common form of mechanical circulatory support used in patients with myocardial ischemia and cardiogenic shock. The physiologic principles of counterpulsation include diastolic augmentation of aortic pressure and systolic reduction of left ventricular afterload, resulting in hemodynamic benefits through increased coronary perfusion pressure and improved myocardial oxygen balance in patients with myocardial ischemia. Major trials have failed to conclusively demonstrate improvements in morbidity and mortality with counterpulsation therapy for patients with acute myocardial infarction (MI), cardiogenic shock, and/or severe coronary artery disease undergoing revascularization therapy, and the debate over its applications continues. Part I of this review focuses on the history of the development of counterpulsation, technical considerations, and complications associated with its use, its physiologic effects, and evidence for its use in myocardial ischemia and cardiogenic shock.

Reduced Number of Platelets During Intra-Aortic Balloon Pumping Counterpulsation Predicts Higher Cardiovascular Mortality After Device Removal in Association with Systemic Inflammation.

Thrombocytopenia is a frequent complication in patients requiring intra-aortic balloon pumping (IABP) counterpulsation. However, its prognostic impact has not been fully addressed. The objective of this study is to evaluate the impact of the change in the platelet number during IABP use on the prognosis after device removal.This is a retrospective observational study. Patients in the intensive cardiac care unit at three Juntendo University hospitals who underwent percutaneous implantation of IABP with or without veno-arterial extracorporeal membrane oxygenation (V-A ECMO), since 2012-2016, were enrolled in the study (n = 439). Patients who died during mechanical circulatory support (n = 47) were excluded. We evaluated the prognostic impact of the ratio of platelet reduction from the baseline (% PLT reduction) during IABP use on cardiovascular mortality after device removal.The median and the range of follow-up period were 298 days and 0-1,869 days, respectively. Unadjusted Kaplan-Meier analysis demonstrated that patients with a higher % PLT reduction had higher cardiovascular (CV) mortality. An adjusted Cox proportional hazard analysis demonstrated that a 10% higher % PLT reduction was associated with higher cardiovascular (CV) mortality (Hazard ratio: 1.3, 95% Confidence interval: 1.1-1.6, P < 0.001). Moreover, % PLT reduction and the maximum C-reactive protein (CRP) level during IABP use were positively correlated (r = 0.326, P < 0.001).The reduced number of platelets during IABP use was associated with an increased risk of CV mortality.

Left ventricular decompression on Veno-arterial extracorporeal membrane oxygenation with intra-aortic balloon Counterpulsation

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used increasingly to support patients with cardiogenic shock (CS). There has been growing recognition of the favorable and unfavorable hemodynamic effects of this therapy and recent interest in the use of other percutaneous circulatory support devices to offset some of the potentially harmful hemodynamic effects. Herein, we provide visual evidence of the effects of intra-aortic balloon pump (IABP) counterpulsation for a patient with peripheral VA-ECMO cannulation.Case presentationA 68 year old man who had undergone orthotopic heart transplantation presented with 2 days of fatigue, orthopnea, and paroxysmal nocturnal dyspnea. On examination, he was tachycardic, hypotensive and hypoxic with cool extremities, consistent with CS. Transthoracic echocardiogram (TTE) showed new severe biventricular dysfunction with a left ventricular ejection fraction of 15%, right heart catheterization demonstrated elevated filling pressures and low output. An IABP was inserted via the left femoral artery with minimal improvement in hemodynamics. He was escalated to VA-ECMO. Repeat TTE demonstrated aortic valve (AV) opening with each cardiac cycle and mild MR. With placement of the IABP on standby Additional file 1: Video 1 (video 0:03), the AV no longer opened. Re-initiation of balloon counterpulsation resulted in resumed AV opening with each beat Additional file 1: Video 1 (video 0:17). He was treated for presumed acute allograft rejection with methylprednisolone, thymoglobulin, intravenous immunoglobulin and plasmapheresis with improvement in allograft function. However, he developed an Enterobacter aerogenes pneumonia and rapidly fatal septic shock.ConclusionsThis case visually demonstrates effective LV decompression by IABP counterpulsation in VA-ECMO support. While the overall effects of LV decompression in patients on VA-ECMO with IABP are still unclear, this report demonstrates one potential mechanism of benefit in the prevention of stagnation of blood flow that may lead to intra-cardiac or aortic root thrombus formation.

Predictors of Hemodynamic Response to Intra-Aortic Balloon Pump Therapy in Patients with Acute Decompensated Heart Failure and Cardiogenic Shock

Introduction There is renewed interest in the utility of the intra-aortic balloon pump (IABP) for short-term and durable support in patients with chronic systolic heart failure (HF) who present with acute decompensation and cardiogenic shock (CS). However, the clinical characteristics of IABP-responders and non-responders remain incompletely defined. We sought to identify predictors of early IABP response to guide optimal use of IABP therapy in this population. Methods We retrospectively analyzed the records of chronic systolic HF patients who presented at our institution between 2011-2018 with acute decompensated HF with hemodynamic evidence of CS and underwent IABP placement. IABP-responder was defined as having an immediate increase in cardiac output (CO) and an immediate decrease in mean pulmonary artery pressure (MPAP) above the median values of the cohort. Logistic regression was used to identify predictors of hemodynamic response. Results During the study period, 218 chronic systolic HF patients underwent IABP insertion for acute decompensation with CS. The mean age was 59.4 ±13.4 years, 79.8% were men, and 38.5% had ischemic cardiomyopathy (ICM). The average hemodynamic response to IABP in the whole cohort was a CO increase of 0.57 ±0.85L/min and a MPAP reduction of 5.1 ±7.6mmHg; IABP-responders had a CO increase of 1.21 ±0.87L/min and a MPAP reduction of 12.1 ±5.9mmHg (figure). Univariable predictors of IABP-response were ICM, presence of severe mitral regurgitation, baseline heart rate, elevated MPAP, and elevated systemic vascular resistance (SVR). Following multivariable logistic regression, independent predictors of IABP-response were elevated baseline SVR (OR 2.05, 95% CI 1.01 - 4.17; p=0.047) and elevated MPAP (OR 2.47, 95% CI 1.23 - 5.00; p=0.01). MPAP reduction decreased the odds of death or need for escalation to another short-term circulatory support device while CO increase did not [OR 0.52 (0.28 - 0.97; p=0.04) vs. 0.83 (0.45 - 1.54; p=0.56)]. Conclusions A subset of chronic systolic HF patients had a robust hemodynamic response to IABP insertion with CO augmentation and MPAP reduction. Elevated baseline SVR and MPAP are predictors of robust response following device insertion. These parameters may be used to identify patients who may respond favorably to IABP counterpulsation therapy.

Intra‐aortic balloon pump counterpulsation in extensive myocardial infarction with persistent ischemia: The SEMPER FI pilot study

This study aimed to prospectively investigate intra-aortic balloon pump counterpulsation (IABP) support in large myocardial infarction complicated by persistent ischemia after primary percutaneous coronary intervention (PCI). Use of IABP is suggested to be effective by increasing diastolic aortic pressure, thereby improving coronary blood flow. This can only be expected with exhausted coronary autoregulation, typical in acute myocardial infarction complicated by persistent ischemia. In this situation, augmented diastolic pressure is expected to increase myocardial oxygenation. One hundred patients with large STEMI complicated by persistent ischemia after primary PCI were randomized to treatment with or without IABP therapy on top of standard care. IABP support was initiated following primary PCI, immediately after inclusion. Primary end point was all-cause mortality, need for (additional) mechanical hemodynamic support, or readmission for heart failure within 6 months. Mean age was 63 ± 10 years, 76% were male. Mean systolic and diastolic blood pressure were 120 ± 25 mmHg and 73 ± 17 mmHg. Mean heart rate was 75 ± 18 mmHg. Before PCI, mean summed ST-deviation was 21 ± 8 mm with only minimal ST-resolution after PCI. One patient in the IABP group reached the primary end point versus four patients in the control group (2% vs. 8%; p = 0.16). After primary PCI, resolution of ST-deviation was significantly more pronounced in the IABP group (73 ± 17%) compared to the control group (56 ± 26%; p < 0.01). In this pilot study, in patients with large STEMI and persistent ischemia after primary PCI, use of IABP showed a nonsignificant decrease in mortality, necessity for (additional) mechanical hemodynamic support or readmission for heart failure at 6 months, and resulted in more rapid ST-resolution.

Hemodynamic Support with Intra Aortic Balloon Pump Differs by Etiology of Cardiogenic Shock

Purpose While intra-aortic balloon pump (IABP) counterpulsation has not been shown to be of benefit in patients with acute myocardial infarction (AMI) with cardiogenic shock (CS), emerging data suggest that patients with acute decompensated heart failure (ADHF) might be more likely to stabilize with this device. Methods Patients with hemodynamic evidence of CS related to either AMI or ADHF who received IABP support were studied retrospectively. Cardiac outputs (CO) and indices (CI) were calculated using the Fick method. Hemodynamics were compared before and after IABP insertion and between the AMI and ADHF cohorts. Results During the study period, 77 patients were supported with IABP for AMI related CS while 132 were supported for ADHF related CS. The mean age was 64.7±13.6 years and 75.1% were men. Mean arterial blood pressure was 75.6±10.6mmHg and 78.4±14.6mmHg among ADHF and AMI patients, respectively (p=0.12). Mean pulmonary artery pressure was higher among those with ADHF (37.9±9.3mmHg vs 33.6±8.9mmHg, p=0.002). Left ventricular ejection fraction was 18.0±8.9% among those with ADHF and 28.9±12.0% among those with AMI (p Conclusion While the degree of hemodynamic compromise was similar between those with CS related to AMI and ADHF, the response to IABP counterpulsation differed significantly between these cohorts suggesting that the device's efficacy may differ between etiologies of CS.

Echocardiographic Weaning in Temporary Mechanical Circulatory Support: The Role of LVOT VTI

Purpose With ongoing research, there is still absence of robust evidence-based recommendations describing use and clinical impact of daily echocardiographic evaluation for mechanically unloaded patients supported with either temporary micro-axial flow (Impella) or intra-aortic balloon counterpulsation (IABP) pumps. Our hypothesis is that in such patients, adjunct protocolized bedside echocardiographic weaning evaluation offers a reliable surrogate of myocardial performance prior to explant. Methods Our description included retrospective evaluation of a database of patients supported with Impella (CP/5.0) or IABP at the Baystate Medical Center Cardiac ICU from 2014 to 2017. Patients included had 1) clinical and hemodynamic cardiogenic shock, 2) prolonged Impella/IABP support requiring ICU level of care, and 3) serial LVOT VTI and cardiac index (CI) checks during support. We excluded patients with intraprocedural Impella insertion/removal. Results were plotted for a total of 80 LVOT VTI and corresponding CI values recorded spanning the implant-explant time. We plotted 3 correlation graphs for VTI to CI (Fig.1), iVTI (indexed LVOT VTI to patients' body surface area) to CI (Fig.2), and rVTI to rCI (relative LVOT VTI and CI to their initial values recorded following implant) (Fig.3). Results Results showed a positive regression of 0.6 for VTI/CI, 0.58 for iVTI/CI, and 0.77 for rVTI/rCI (p-value Conclusion As our data indicates, we provide a real-world standardized method that objectively focuses on routine evaluation of LVOT VTI as a surrogate of myocardial performance in cardiogenic shock requiring prolonged mechanical unloading. This method should therefore be taken one step further and considered for daily assessment of myocardial performance while weaning the support settings, as illustrated in our example (Fig.4), and be protocolized as a standard weaning parameter in shock centers.

75-Year-Old Man With Chest Pain and Dyspnea

A 75-year-old man presented to the emergency department with a 6-day history of dyspnea and substernal exertional chest pain with radiation to the jaw and left arm. He reported managing his chest pain with ibuprofen, but the chest pain continued, which prompted him to present for further evaluation. His medical history included diabetes mellitus type 2 complicated by neuropathy, hypertension, and hyperlipidemia. He had a 20-year 1.5 pack per day smoking history and did not use alcohol or illicit drugs. He did not have any family history of coronary artery disease. His medications included metformin, insulin, hydrochlorothiazide, and atorvastatin. Examination revealed an elderly man with a body mass index of 26 kg/m2 who was in no acute distress. He was afebrile and had a pulse rate of 76 beats/min, blood pressure of 138/88 mm Hg, respiratory rate of 17 breaths/min, and oxygen saturation of 100% while breathing room air. Cardiac and pulmonary examination findings were unremarkable. There was no elevated jugular venous distention or lower extremity edema. He did not report any change in chest pain with an adjustment in position, respiration, or palpation of the anterior chest wall. Electrocardiography revealed evidence of T-wave inversion and 1-mm downsloping ST-segment depression in leads V5, V6, I, and aVL. His initial troponin T level was elevated at 0.04 ng/mL. He was given 324 mg of aspirin and supplemental oxygen. After administration of sublingual nitroglycerin, he stated that his chest pain improved. Troponin T level at 3 hours was 0.09 ng/mL.1.Which one of the following diagnoses is most consistent with this patient’s clinical picture?a.Acute pericarditisb.Costochondritisc.Stress cardiomyopathyd.Pulmonary embolisme.Acute coronary syndrome Acute pericarditis is a potential cause of new-onset chest pain that is often difficult to distinguish from other causes of chest pain. However, the chest pain of acute pericarditis is typically sharp, pleuritic, and improved by sitting up and leaning forward. Additionally, a pericardial friction rub, characterized by a scratching or grating quality, may be present and is best heard with the diaphragm of the stethoscope during held inspiration. Electrocardiographic findings are characterized by widespread concave ST elevation or PR depression as well as PR elevation in the aVR lead. Troponin elevation in patients with acute pericarditis suggests myocardial involvement, and such patients should be considered to have myopericarditis. Costochondritis is less likely in this patient given that his pain was not reproducible by palpation nor reduced with nonsteroidal anti-inflammatory drug therapy, and the elevation in cardiobiomarker levels also pointed against such a diagnosis. The onset of stress cardiomyopathy is typically preceded by a physical or emotional stress and should be considered a diagnosis of exclusion based on invasive angiographic evaluation. Among patients with massive and submassive pulmonary embolism, troponin elevation occurs 1 in 3 and 1 in 7 patients, respectively.1Meyer T. Binder L. Hruska N. Luthe H. Buchwald A.B. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction.J Am Coll Cardiol. 2000; 36: 1632-1636Crossref PubMed Scopus (279) Google Scholar However, the patient’s improvement in chest pain with nitroglycerin, the presence of numerous cardiac risk factors, and major troponin delta over time suggested an alternative diagnosis. The patient’s clinical presentation was consistent with acute coronary syndrome, specifically non–ST-segment elevation myocardial infarction. He underwent cardiac catheterization and was found to have a critical stenosis of the first obtuse marginal branch as well as the circumflex artery. Additionally, disease was present in the right coronary artery and left anterior descending artery. He underwent drug-eluting stent placement in the circumflex and second obtuse marginal artery. He had an uneventful hospital course postcatheterization until 2 days later when he experienced recurrence of shortness of breath and substernal, nonpleuritic, and nonpositional chest pain. Repeated blood pressure measurement revealed a blood pressure of 85/40 mm Hg. Cardiac auscultation revealed a harsh early systolic murmur loudest at the apex without a thrill when the patient was laying in the left lateral decubitus position. Chest radiography revealed bilateral pulmonary infiltrates consistent with pulmonary edema.2.Based on this patient’s history and physical examination findings, which one of the following complications of myocardial infarction is most likely?a.Dressler syndromeb.Ventricular septal rupturec.Left ventricular aneurysmd.Acute mitral regurgitatione.Right ventricular failure Typical physical examination findings in Dressler syndrome include pleuritic chest pain, fever, leukocytosis, and elevation in markers of inflammation including erythrocyte sedimentation rate and C-reactive protein.2Dressler W. A post-myocardial infarction syndrome: preliminary report of a complication resembling idiopathic, recurrent, benign pericarditis.J Am Med Assoc. 1956; 160: 1379-1383Crossref PubMed Scopus (119) Google Scholar Most commonly, there is a latent period of weeks to months between the initial injury and the development of symptoms. These symptoms and time frame are not consistent with those our patient experienced. Chest radiography should be performed in all patients with suspected Dressler syndrome and may reveal a postoperative pericardial effusion, which warrants further evaluation by echocardiography. Ventricular septal rupture manifests with onset of hypotension, biventricular failure (most often right-sided), and a new harsh holosystolic murmur loudest at the lower left or possibly right sternal borders. There may also be a loud pulmonic component of the second heart sound and a palpable thrill, which occur due to increased pulmonic flow resulting in pulmonary hypertension.3Jones B.M. Kapadia S.R. Smedira N.G. et al.Ventricular septal rupture complicating acute myocardial infarction: a contemporary review.Eur Heart J. 2014; 35: 2060-2068Crossref PubMed Scopus (138) Google Scholar Left ventricular aneurysm is typically the result of myocardial infarction, more often in the setting of a large anterior infarct. The presence of a left ventricular aneurysm should be suspected in patients with an extensive anterior myocardial infarction who experience heart failure symptoms, ventricular arrhythmias, or systemic embolization. Acute mitral regurgitation may manifest with a mid, late, or holosystolic murmur loudest at the apex; a thrill is generally not present. However, approximately 50% of patients with acute ischemic mitral regurgitation do not have an audible murmur.4Bursi F. Enriquez-Sarano M. Nkomo V.T. et al.Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.Circulation. 2005; 111: 295-301Crossref PubMed Scopus (429) Google Scholar Causes of acute mitral regurgitation after myocardial infarction most commonly involve papillary muscle dysfunction. Clinical manifestations include acute onset of hypotension and pulmonary edema. In contradistinction, patients with right ventricular failure classically manifest with a triad of hypotension, jugular venous distention, and lack of pulmonary edema. The patient was determined to likely have acute mitral regurgitation based on auscultation in the left lateral decubitus position and chest radiographic findings of new pulmonary edema.3.Which one of the following diagnostic tests is the most appropriate next step in management of this patient?a.Chest computed tomographyb.Cardiac magnetic resonance imagingc.Right- and left-sided heart catheterizationd.Electrocardiographye.Transthoracic echocardiography Acute mitral regurgitation is rarely evaluated by cardiac computed tomography and magnetic resonance imaging, and importantly, patients must be stable in order to utilize these imaging modalities.5Morris M.F. Maleszewski J.J. Suri R.M. et al.CT and MR imaging of the mitral valve: radiologic-pathologic correlation.Radiographics. 2010; 30: 1603-1620Crossref PubMed Scopus (50) Google Scholar Left-sided heart catheterization would not be indicated at this stage because the new clinical findings are likely not secondary to a new coronary event but rather a mechanical complication of the original infarction. Right-sided heart catheterization allows for invasive assessment of circulatory hemodynamics. Large V waves in the pulmonary wedge pressure curve can be seen in 60% of patients with papillary muscle rupture, but a large V wave alone is nondiagnostic because it can also be seen in patients with ventricular septal rupture or severe left ventricular dysfunction.6Goldman A.P. Glover M.U. Mick W. et al.Role of echocardiography/Doppler in cardiogenic shock: silent mitral regurgitation.Ann Thorac Surg. 1991; 52: 296-299Abstract Full Text PDF PubMed Scopus (16) Google Scholar Furthermore, right-sided heart catheterization is invasive, and in contemporary practice there are more convenient noninvasive approaches to achieve the correct diagnosis. Electrocardiography in patients with chronic mitral regurgitation may exhibit left atrial enlargement, left ventricular hypertrophy, and atrial fibrillation. Furthermore, evidence of left ventricular enlargement may occur in patients with severe chronic mitral regurgitation. However, these findings may be absent in patients with acute mitral regurgitation. Two-dimensional transthoracic echocardiography is highly useful in assessing mitral regurgitation and should be the first test to pursue if the diagnosis is being contemplated because it can demonstrate the mechanism of mitral valve insufficiency. A ruptured papillary muscle or chordae can also be frequently seen moving in the left ventricle. However, in nearly 35% of patients with papillary rupture, the ruptured head does not prolapse into the left atrium, necessitating the need for other imaging modalities including transesophageal echocardiography.7Moursi M.H. Bhatnagar S.K. Vilacosta I. San Roman J.A. Espinal M.A. Nanda N.C. Transesophageal echocardiographic assessment of papillary muscle rupture.Circulation. 1996; 94: 1003-1009Google Scholar Furthermore, as the mitral apparatus is a posterior structure, transesophageal echocardiography has a greater sensitivity of 95% to 100% and should be considered in patients in whom transthoracic echocardiography could not fully delineate the mitral subvalvular apparatus. The addition of color flow Doppler to measure eccentric regurgitant jets increases the sensitivity of both transthoracic echocardiography and transesophageal echocardiography. The patient underwent transthoracic echocardiography, which was considered suboptimal due to limited acoustic windows, and subsequently underwent transesophegeal echocardiography, which demonstrated severe mitral regurgitation with evidence of papillary muscle rupture.4.Which one of the following therapies will provide the most definitive long-term management?a.Diuretic therapy and nitratesb.Insertion of intra-aortic balloon pumpc.Surgical mitral valve repair/replacementd.MitraClip proceduree.Coronary artery bypass grafting Once the diagnosis of papillary muscle rupture has been established, medical therapy should be initiated and urgent surgical intervention should be sought for definitive management. Medical therapy is centered on preload and afterload reduction with a traditional combination of loop diuresis and intravenous nitrates. Intra-aortic balloon pump counterpulsation placement during acute mitral regurgitation complicated by cardiogenic shock lowers aortic impedance, resulting in reduced mitral regurgitation and increased cardiac output. The mortality rate in patients with papillary muscle rupture undergoing surgical intervention is approximately 20% to 25%, but the mortality rate of patients who do not undergo surgical intervention approaches 100% at 2 months.8Sanders R.J. Neubuerger K.T. Ravin A. Rupture of papillary muscles: occurrence of rupture of the posterior muscle in posterior myocardial infarction.Dis Chest. 1957; 31: 316-323Abstract Full Text Full Text PDF Scopus (89) Google Scholar Although the superiority of mitral valve repair over mitral valve replacement has never been definitively shown due to conflicting data, small sample size, and prolonged recruitment periods, mitral valve repair is often performed if experienced surgeons are available. Furthermore, mitral valve repair should be performed only when there is no evidence of papillary muscle necrosis. The MitraClip (Abbott) is the only US Food and Drug Administration–approved device for transcatheter mitral valve repair, a minimally invasive technique for the treatment of symptomatic, chronic, moderate to severe mitral regurgitation. The 2014 American Heart Association/American College of Cardiology guidelines suggested patients should meet all of the following criteria to be considered for the MitraClip: (1) severely symptomatic (New York Heart Association class III or IV) heart failure despite medical therapy, (2) chronic moderate to severe or severe primary mitral regurgitation, (3) favorable anatomy for repair, (4) reasonable life expectancy, and (5) prohibitive surgical risk due to comorbidities.9Nishimura R.A. Otto C.M. Bonow R.O. et al.American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63 ([published correction appears in J Am Coll Cardiol. 2014;63(22):2489]): e57-e185Crossref PubMed Scopus (2085) Google Scholar Previous research has shown the addition of coronary artery bypass grafting in patients who underwent mitral valve surgery for ischemic papillary muscle rupture did not influence the acute postoperative course.10Schroeter T. Lehmann S. Misfeld M. et al.Clinical outcome after mitral valve surgery due to ischemic papillary muscle rupture.Ann Thorac Surg. 2013; 95: 820-824Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Furthermore, this patient had complete percutaneous revascularization at the time of initial presentation. The patient was stabilized with medical therapy by administration of diuretics and nitrates before undergoing emergent bioprosthetic mitral valve replacement successfully.5.Which one of the following long-term anticoagulation regimens after mitral valve replacement is the most appropriate?a.Aspirinb.Warfarinc.Aspirin and warfarind.Dabigatrane.Low-molecular-weight heparin Anticoagulation is indicated in the setting of replacement of the mitral valve in order to preserve the longevity of the prosthesis and with the goal of preventing the adverse outcome of prosthetic valve thrombosis and dysfunction. Aspirin monotherapy does not provide adequate anticoagulation in the setting of mechanical mitral valve replacement. Instead, anticoagulation with a vitamin K antagonist (VKA), such as warfarin, is suggested to achieve a target international normalized ratio of 3 in addition to taking into account patient-specific thromboembolic risk factors. Additionally, aspirin therapy (75-100 mg/d) concurrent with a VKA has been suggested for all patients with a mechanical prosthetic valve. The benefit of antiplatelet therapy in addition to VKA therapy in patients with a mechanical prosthetic valve was summarized in previous work that found that combined antiplatelet and anticoagulant therapy reduced the risk of thromboembolism and mortality compared to anticoagulant therapy alone.11Massel D.R. Little S.H. Antiplatelet and anticoagulation for patients with prosthetic heart valves.Cochrane Database Syst Rev. 2013; 7: CD003464Google Scholar However, the need for anticoagulation for patients with bioprosthetic valves is less clear. It has been suggested that patients with a surgical bioprosthetic mitral valve should be anticoagulated with a VKA for the first 3 to 6 months to achieve an international normalized ratio of 2.5. The use of aspirin at 75 mg to 100 mg alone is recommended in all patients with a bioprosthetic mitral valve, consistent with the 2017 American Heart Association/American College of Cardiology focused update for the management of patients with valvular disease.12Nishimura R.A. Otto C.M. Bonow R.O. et al.2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2017; 70: 252-289Crossref PubMed Scopus (1812) Google Scholar Lifelong oral anticoagulation is recommended for patients with a mitral valve prosthesis who have other indications for anticoagulation, specifically atrial fibrillation, venous thromboembolism, hypercoagulable state, or an ejection fraction of less than 35%.13Baumgartner H. Falk V. Bax J.J. et al.ESC Scientific Document Group2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Crossref PubMed Scopus (2) Google Scholar Direct oral anticoagulants, such as rivaroxaban, should not be used in patients with mechanical valves based on findings of the RE-ALIGN (Randomised, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients After Heart Valve Replacement) study that demonstrated increased bleeding and thrombotic complications compared to warfarin.14Eikelboom J.W. Connolly S.J. Brueckmann M. et al.RE-ALIGN InvestigatorsDabigatran versus warfarin in patients with mechanical heart valves.N Engl J Med. 2013; 369: 1206-1214Crossref PubMed Scopus (1002) Google Scholar Low-molecular-weight heparin is a useful injectable anticoagulant but is inconvenient and cost-ineffective to use as a long-term agent. Its role in individuals with valve prosthesis is typically to help bridge toward a therapeutic level of anticoagulation with warfarin. After the patient underwent mitral valve replacement, an intra-aortic balloon pump and inotropic agents were used in the early postoperative period to aid in mechanical circulatory support. He was initiated on low-molecular-weight heparin as a bridge to warfarin in addition to aspirin. The patient was weaned from all intravenous medications and discharged to a rehabilitation facility to aid in strength training. The 3 main mechanical complications of acute myocardial infarction are ventricular septal rupture, left ventricular free wall rupture, and acute mitral regurgitation. The mechanisms of mitral regurgitation in the acute stage of myocardial infarction involve papillary muscle dysfunction, papillary muscle rupture, or rupture of the chordae tendineae. In patients with chronic mitral regurgitation after myocardial infarction, the etiology involves mitral annulus dilatation, tethering of mitral leaflets, and localized wall motion abnormalities. Papillary muscle rupture accounts for 5% of deaths in patients with acute myocardial infarction and usually occurs 2 to 7 days after the infarct.15Lavie C.J. Gersh B.J. Mechanical and electrical complications of acute myocardial infarction.Mayo Clin Proc. 1990; 65 ([published correction appears in Mayo Clin Proc. 1990;65(7):1032]): 709-730Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Rupture of the posteromedial papillary muscle occurs 6 to 12 times more frequently than rupture of the anterolateral papillary muscle because of differences in blood supply; the anterolateral papillary muscle receives dual blood supply from the first marginal artery of the circumflex artery and the first diagonal artery from the left anterior descending artery, whereas the posteromedial papillary muscle receives blood flow from the posterior descending artery alone.16Roberts W.C. Cohen L.S. Left ventricular papillary muscles: description of the normal and a survey of conditions causing them to be abnormal.Circulation. 1972; 46: 138-154Crossref PubMed Scopus (135) Google Scholar Papillary muscle rupture occurs in patients with both non–ST-elevation and ST-elevation infarcts. Although the development of a new systolic murmur may clue the clinician to a possible diagnosis of papillary rupture, patients with a complete papillary muscle rupture or with severe left ventricular dysfunction may not have an audible murmur secondary to early equalization of left ventricular and left atrial pressures. If there is clinical suspicion of acute mitral regurgitation, emergent bedside transthoracic echocardiography is warranted in addition to alerting a cardiovascular surgeon. Transesophegeal echocardiography may be necessary for complete delineation of the anatomic and physiologic perturbations observed in this setting. Prompt recognition, initiation of medical therapy, and emergent surgery are the cornerstones of treatment in patients with papillary muscle rupture secondary to acute myocardial infarction. Among patients who had papillary muscle dysfunction after acute myocardial infarction, the presence of a systolic murmur was associated with a higher hospital and 1-year mortality than those without systolic murmurs and had 2.5-fold shorter average time to reinfarction. Despite a mortality risk approaching 25% in patients undergoing surgery, medical therapy alone has poor results, with mortality rates reaching 75% and 95% at 24 hours and 2 weeks postinfarct, respectively.17Manning W.J. Waksmonski C.A. Boyle N.G. Papillary muscle rupture complicating inferior myocardial infarction: identification with transesophageal echocardiography.Am Heart J. 1995; 129: 191-193Google Scholar, 18Kishon Y. Oh J.K. Schaff H.V. Mullany C.J. Tajik A.J. Gersh B.J. Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients.Mayo Clin Proc. 1992; 67: 1023-1030Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar Furthermore, medical therapy with a delay in surgery has been associated with poor outcomes as well.17Manning W.J. Waksmonski C.A. Boyle N.G. Papillary muscle rupture complicating inferior myocardial infarction: identification with transesophageal echocardiography.Am Heart J. 1995; 129: 191-193Google Scholar