Intra-aortic Balloon Pump In Patients Research Articles

Intra-aortic balloon pump in patients with extracorporeal cardiopulmonary resuscitation after cardiac arrest caused by acute coronary syndrome

BackgroundThis study evaluated the association between intra-aortic balloon pump (IABP) use in patients with out-of-hospital cardiac arrest (OHCA) caused by acute coronary syndrome (ACS) who received extracorporeal cardiopulmonary resuscitation (ECPR) and 30-day outcomes. MethodsThis study was a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter registry study involving 36 participating institutions in Japan. Patients with cardiac arrest caused by ACS who received ECPR were divided into two groups depending on whether or not they received IABP. The primary outcome was 30-day survival. Subgroup analysis was performed to detect what type of patients were mostly associated with improved outcomes. ResultsOf 2,157 patients registered in the SAVE-J II study, 877 patients were enrolled in this study, 702 patients in the IABP group and 175 patients in the non-IABP group. Multivariable logistic regression analysis did not reveal a significant difference in 30-day survival (OR 1.37, 95% CI 0.91–2.07, p = 0.13). In the subgroup analysis, 30-day survival among patients without percutaneous coronary intervention (PCI) and stenosis of multiple coronary vessels were associated with IABP use. ConclusionsIABP use in patients with OHCA with ACS who received ECPR is not associated with 30-day survival. The use of IABP in patients who did not have PCI and have multiple coronary vessel stenoses warrants further study.

Abstract 381: Simultaneous Use of VA-ECMO and Impella (ECPELLA) Improves Mid-Term Mortality in Patients With Refractory Cardiac Arrest or Cardiac Shock Who Required VA-ECMO

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an effective therapy to rescue patients with refractory cardiogenic shock, including cardiac arrest. VA-ECMO increase damaged left ventricular (LV) afterload. The intra-aortic balloon pump (IABP) has been often used as the additional circulatory support for LV unloading. However, the effectiveness of combining VA-ECMO with IABP has not been definitively established. The Impella , a percutaneous micro-axial pump, can reduce damaged LV preload with circulatory support, which may have significant effect on clinical outcome by concomitant use of VA-ECMO and Impella (ECPELLA). Objective: This single-site cohort study aimed to assess the impact of ECPELLA compared to VA-ECMO with or without IABP in patients with refractory cardiogenic shock who received VA-ECMO treatment. Methods: We retrospectively reviewed 275 consecutive patients who received VA-ECMO from January 2012 through December 2022 in our institute. The patients were divided into two groups, ECEPLLA (n = 81) and VA-ECMO with or without IABP (n = 194). The primary outcome of this study was the 180-day all-cause mortality rate. Results: There were no significant differences in age, gender ratio, prevalence of coronary risk factors, serum lactate levels at the emergency room (ER), the rate of extracorporeal cardiopulmonary resuscitation (E-CPR), and instances of out-of-hospital cardiac arrest between the groups. The ECPELLA groups had a significantly higher rate of acute coronary syndrome and a lower prevalence of chronic kidney disease. Kaplan-Meier analysis demonstrated that the 180-day all-cause mortality was significantly lower in the ECPELLA group compared to the VA-ECMO group (p < 0.001). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.27 [10 years increase]; 95% confidence interval [CI], 1.13-1.42, p < 0.001), E-CPR (HR 1.43; 95% CI 1.02-2.00, p = 0.04), lactate level at ER (HR 1.07; 95% CI 1.04-1.10, p < 0.001), and ECPELLA (HR, 0.55, 95% CI, 0.40-0.76, p < 0.001) were significantly associated with the 180-day all-cause mortality. Conclusion: ECPELLA was associated with improvement of mid-term mortality in patients with refractory cardiogenic shock who received VA-ECMO.

Abstract 11322: Comparative Outcomes of Impella and Intra-Aortic Balloon Pump for Left Ventricular Unloading Among Patients With Cardiogenic Shock on Veno-Arterial Extracorporeal Membrane Oxygenation

Background: Cardiogenic shock (CS) is associated with high morbidity and mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with CS. Although Impella or Intra-aortic balloon pump (IABP) is frequently used for left ventricular (LV) unloading for increased afterload during VA-ECMO therapy, there are scarce comparative outcomes data for these devices. Aims: To compare short-term outcomes of Impella and IABP in patients on VA-ECMO for CS. Methods: Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes of CS patients requiring VA-ECMO based on multivariable regression and propensity score methods. Results: Of 15,980 patients on VA-ECMO, IABP and Impella were used in 19.4% and 16.4% patients, respectively. The proportion of patients managed with Impella for LV unloading significantly increased from 2016 to 2020 (6.5% vs. 25.8%; P-trend<0.001). In-hospital mortality was higher in Impella group (54.8%) compared with ECMO only (50.4%) and IABP (48.4%) groups. After adjustment, LV unloading using IABP vs ECMO only was associated with lower in-hospital mortality (OR, 0.83; 95% CI, 0.70-0.98). LV unloading using Impella vs ECMO only had similar in-hospital mortality (OR, 1.09; 95% CI, 0.91-1.31) but was associated with more bleeding (OR, 1.21; 95% CI, 1.04-1.41) and more acute kidney injury (AKI) requiring hemodialysis (HD) (OR, 1.42; 95% CI, 1.13-1.77). LV unloading with Impella vs IABP was associated with greater risk of AKI requiring HD (OR, 1.49; 95% CI, 1.13-1.97), higher in-hospital mortality (OR, 1.32; 95% CI, 1.10-1.60), and high 40-day mortality (HR, 1.25; 95% CI, 1.17-1.32). Conclusions: LV unloading using Impella, compared with IABP, was not associated with improved survival at 40 days in patients treated with VA-ECMO for CS, but was associated with increased adverse events. These findings suggest a need for further studies to guide clinical practice of LV unloading in CS.

Beneficial Effects of IABP in Anterior Myocardial Infarction Complicated by Cardiogenic Shock.

Background and Objectives. Recent guidelines have downgraded the routine use of the intra-aortic balloon pump (IABP) in patients with cardiogenic shock (CS) due to ST-elevation myocardial infarction (STEMI). Despite this, its use in clinical practice remains high. The aim of this study was to evaluate the prognostic impact of the IABP in patients with STEMI complicated by CS undergoing primary PCI (pPCI), focusing on patients with anterior MI in whom a major benefit has been previously hypothesized. Materials and Methods. We enrolled 2958 consecutive patients undergoing pPCI for STEMI in our department from 2005 to 2018. Propensity score matching and mortality analysis were performed. Results. CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. In the propensity-matched analysis, the use of the IABP was associated with a lower 30-day mortality (39.3% vs. 60.9%, p = 0.032) in the subgroup of patients with anterior STEMI. Conversely, in the whole group of CS patients and in the subgroup of patients with non-anterior STEMI, IABP use did not have a significant impact on mortality. Conclusions. The use of the IABP in cases of STEMI complicated by CS was found to improve survival in patients with anterior infarction. Prospective studies are needed before abandoning or markedly limiting the use of the IABP in this clinical setting.

Left Ventricular Unloading With Impella Versus IABP in Patients With VA-ECMO: A Systematic Review and Meta-Analysis

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2=71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2=82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2=66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.

Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting.

Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined. A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates. Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028). Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Clinical implication of intra-aortic balloon pumping in patients with Takotsubo syndrome and cardiogenic shock.

Clinical implication of intra-aortic balloon pumping in patients with Takotsubo syndrome and cardiogenic shock.

Comparison between Intra-Aortic Balloon Pump and Levosimendan as Treatment Modalities for Cardiogenic Shock Post Cardiac Surgery

Purpose: Post cardiac surgery cardiogenic shock is one of the major life threatening complications of open heart surgeries. Two modalities are widely used to improve the cardiac output and overcome the acute postoperative complication beside other conventional treatment including mechanical ventilator, inotropes and vasopressors. Those modalities are levosimendan and Intra-aortic balloon pump. The purpose of this study is to investigate the prognosis of levosimendan vs IABP in patients who developed cardiogenic shock post cardiac surgery.
 Methodology: This was a prospective observational study conducted as national heart institute, Egypt on 50 patients who developed cardiogenic shock post cardiac surgery and managed by either levosimendan or Intra-aortic balloon Pump (IABP) beside other conventional therapies. Patients were then divided into two groups according to the modality used. Group I: patients who were managed by levosimendan and group II: patients who were managed by IABP. Two groups were then compared according to baseline preoperative characteristics and in-hospital course and one month follow up post discharge echocardiography.
 Findings: No significant difference regarding between in-hospital mortality between levosimendan, 44% and IABP, 52% P value 0.5. Levosimendan was associated with significantly shorter ICU stay, 5.56±2.85 compared to IABP, 8±3.34 days (P value 0.02). Levosimendan seems to be a better option than IABP or at least equivalent to it in postoperative cardiogenic shock.
 Recommendations: Levosimendan is an alternative cost effective modality for patients with post-operative low cardiac output syndrome especially when IABP isn’t available.
  

Intra-aortic balloon pump use in out-of-hospital cardiac arrest patients who underwent extracorporeal cardiopulmonary resuscitation

AimTo investigate the effect of intra-aortic balloon pump (IABP) use after extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation (ECPR) on short-term neurological outcomes and survival in patients with out-of-hospital cardiac arrest (OHCA). MethodsWe retrospectively analysed data collected between June 2014 and December 2019 from the Japanese OHCA registry. Adult patients (aged ≥18 years) who underwent ECPR were included. We divided the patients into those who received IABP and those who did not receive IABP. The primary outcome was the 30-day favourable neurological outcomes in survived patients. The secondary outcome was the 30-day survival. We performed propensity score matching (PSM) to adjust for confounding factors after multiple imputations of missing data. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression analysis after PSM to adjust for confounding factors after IABP initiation. ResultsAmong 2135 adult patients who underwent ECPR, 1173 received IABP. In 842 matched patients, IABP use was associated with survival (aOR, 1.98; 95% CI, 1.39–2.83; p < 0.001). However, IABP use was not significantly associated with the 30-day neurologically favourable outcome in 190 survived patients (aOR, 1.22; 95% CI, 0.79–1.89; p = 0.36). ConclusionThe use of IABP in patients with OHCA who underwent ECPR was associated with 30-day survival. Among survived patients, there was no significant association between IABP use and 30-day neurological outcome. A further well-designed prospective study is needed.

Intra-aortic Balloon Pump Versus Impella in Managing Cardiogenic Shock After Myocardial Infarction: Literature Review.

Despite early revascularization and supportive medical therapies, acute myocardial infarction with cardiogenic shock (AMICS) remains the leading cause of death in patient's with myocardial infarction. Intra-aortic balloon pump (IABP) has been the device of choice for these patients but has failed to show mortality benefit over medical therapy alone. The Impella (AbioMed, Danvers, Massachusetts) is a more recently developed alternative in bridging patients to recovery. The aim of this study was to evaluate available evidence comparing mortality with the use of Impella (2.0 or CP) versus IABP in patients with AMICS. PubMed, CINAHL, EMBASE, and Scopus were searched to find articles comparing the outcomes of IABP versus Impella in AMICS patients. A total of 7 articles met the inclusion criteria. Thirty-day mortality was the primary outcome observed. Secondary outcomes included myocardial recovery and complications from device implantation. All studies support that there is no statistically significant reduction in mortality when utilizing the Impella over the IABP. Further research in an adequately powered randomized clinical trial is needed to shed light on the clinical characteristics of patients after AMICS who would benefit from 1 type of mechanical circulatory support over another. The therapy chosen is determined by provider discretion and skill set, as well as device availability. It is important for all care team members, including the critical care nurse, to understand the implications and complications associated with each therapy, so care can be catered to the individual patient's needs.

[Intra-aortic balloon pump in patients with myocardial infarction and cardiogenic shock of stages A and B].

This article presents two clinical cases of patients with myocardial infarction and stage A (at risk) and B (beginning) cardiogenic shock who underwent intra-aortic balloon counterpulsation (IABP). In patients with a high risk of classic cardiogenic shock and/or the no-reflow phenomenon, stenting of the infarct-related coronary artery during this type of mechanical circulatory support was performed without complications. Theoretical and practical aspects of using IABP at different stages of cardiogenic shock are discussed.

Comparative study between levosimendan and intra-aortic balloon pump in high risk patients undergoing beating heart coronary artery bypass surgery

Background: Preoperative left ventricular dysfunction is an independent risk factor for perioperative mortality and morbidity and is also associated with postoperative low cardiac output syndrome. IABP improved outcomes in high-risk cardiac patients. However, installation of the balloon has many disadvantages. Recently, a new drug named levosimendan is commonly used as an inotropic support with no increase oxygen demand of myocardium. Objective: The purpose of our study was to compare the efficiency of levosimendan versus intra-aortic balloon pump in patients with poor left ventricular function undergoing coronary artery bypass grafting (CABG) with ejection fraction less than 35%. Patients and Methods: Forty patients with elective multi-vessel off-pump CABG at Al-Azhar University, Air force Specialized and Al-Assema Hospitals were randomized into 2 groups, according to the treatment they received – either levosimendan (Levo group) or intra-aortic balloon counter pulsation (IABP group), and compared with respect to The use of inotropic drugs,  Hemodynamics, ICU stay, hospital stay and in-hospital mortality. Results: There were no differences in preoperative characteristics including patients’ age, sex, BMI, and comorbidities. The Levosemindan group had shorter ICU and hospital stays as compared to IABP group with comparable hemodynamic functions, time of mechanical ventilation and mortality rate. 

Intra-aortic balloon pump in patients with acute advanced heart failure. Results from a single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with advanced heart failure are frequently referred to cardiac intensive care unit (CICU) for hemodynamic support. Despite optimum pharmacological therapy many of these patients persist in critical condition, demanding short term circulatory support until recovery or heart transplantation. Intra-aortic balloon pump is commonly used in patients with advanced heart failure in order to stabilize hemodynamically compromised patients as bridge to decision for further therapies. Purpose To investigate the outcomes of patients with acute advanced heart failure referred to cardiac intensive care unit and supported with short term mechanical support. To explore the hemodynamic effects of the Intra-aortic balloon pump therapy in these patients. Material &amp; Method We retrospectively analyzed the data from 104 patients with acute advanced heart failure (either as worsening of existing symptoms of chronic HF or as first onset of HF). All patients had severe left ventricular dysfunction, which was frequently associated with right ventricular dysfunction and increased NT pro BNP levels. Demographic data were collected including co-morbidities. Laboratory data included NT-pro BNP, total bilirubin, serum creatinine, urea and baseline e GFR (MDRD Formula). All patients received IABP support and underwent right heart catheterization. Measurements were made before and after the insertion of the IABP. The study has been approved by the Scientific Committee and the Ethics Committee of the Hospital. Results The mean age of the sample was 44 ± 12 years. 76 patients (73, 08%) were male. 20 patients (19, 23%) were of ischemic etiology. The median time on IABP support for the entire cohort was 13 days (3 – 41, 25). There was statistically significant decrease in the NT-pro BNP levels (p&amp;lt;0, 0001). There was improvement in renal function (e GFR (p&amp;lt;0, 0001) and urea levels (p&amp;lt; 0,001)). There was statistically significant improvement in the right heart catheterization measurements (decrease of the right atrium pressure (p &amp;lt;0, 0001), of the PA pressure (p&amp;lt;0,001), and of the pulmonary capillary wedge pressure (p&amp;lt;0,001)). IABP provided clinical stabilization in 88 patients (87, 62%), that is completed pre-transplant evaluation and proceeded in surgery with permanent mechanical support or heart transplantation or transfer to regular ward, while 16 patients (15, 38%) ended up in CICU while being on IABP. Conclusions In this single center study the use of IABP improved the laboratory findings and the hemodynamic status of patients admitted in the cardiac intensive care unit with acute advanced heart failure. It was an effective method of managing patients as bridge to decision for further therapies.

Percutaneous Right Axillary Intra-aortic Balloon Pump in Patients with Advanced Heart Failure.

Percutaneous Right Axillary Intra-aortic Balloon Pump in Patients with Advanced Heart Failure.

Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock

HomeJournal of the American Heart AssociationVol. 11, No. 7Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessEditorialPDF/EPUBIntra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock Agam Bansal, MD, Dhiran Verghese, MD and Saraschandra Vallabhajosyula, MD, MSc Agam BansalAgam Bansal https://orcid.org/0000-0002-6404-7436 Department of Medicine, , Cleveland Clinic Foundation, , Cleveland, , OH Search for more papers by this author , Dhiran VergheseDhiran Verghese https://orcid.org/0000-0003-1904-7397 Section of Advanced Cardiac Imaging, , Division of Cardiovascular Medicine, , Department of Medicine, , Harbor‐UCLA Medical Center, , Los Angeles, , CA Search for more papers by this author and Saraschandra VallabhajosyulaSaraschandra Vallabhajosyula * Correspondence to: Saraschandra Vallabhajosyula, MD, MSc, Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, 306 Westwood Avenue, Suite 401, High Point, NC 27262. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0002-1631-8238 Division of Cardiovascular Medicine, , Department of Medicine, , Wake Forest University School of Medicine, , Winston‐Salem, , NC Search for more papers by this author Originally published4 Apr 2022https://doi.org/10.1161/JAHA.122.025274Journal of the American Heart Association. 2022;11:e025274This article is a commentary on the followingOutcomes of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra‐Aortic Balloon Pumping for Treatment of Acute Myocardial Infarction Complicated by Cardiogenic ShockOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 4, 2022: Ahead of Print Cardiogenic shock (CS) affects between 40 000 and 50 000 individuals in the United States per year and is the leading cause of in‐hospital mortality following acute myocardial infarction (AMI).1, 2, 3 Even with advances in acute cardiovascular care, including primary percutaneous coronary intervention, 30‐day mortality for patients with AMI‐CS remains ≈40%.1 Despite the hemodynamic advantage of mechanical circulatory support devices in AMI‐CS, there are limited randomized data supporting their use.4 Over the past decade, there has been an increase in the use of veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) in the management of refractory cardiogenic shock, because it offers not only a high cardiac output with biventricular support but also respiratory support.5 However, peripheral VA‐ECMO is limited by the significant increase in afterload because of retrograde aortic flow, which may be deleterious in CS, especially from AMI.5 Multiple techniques have been proposed to offload the left ventricle (LV) in patients on VA‐ECMO, including a pigtail catheter in the LV or pulmonary artery, atrial septostomy, and concomitant mechanical circulatory support such as the intra‐aortic balloon pump (IABP) or a percutaneous left ventricular assist device. The IABP has remained the most commonly used modality of LV decompression studied in literature because of its ubiquitous availability, ease of insertion, relatively small arteriotomy, theoretical benefit of diastolic augmentation and therefore coronary perfusion, and lastly, the ease of maintenance in the cardiac intensive care unit.6In this issue of the Journal of the American Heart Association (JAHA), Nishi et al7 use the nationwide Japanese Registry of All Cardiac and Vascular Disease and describe a large retrospective cohort of 3815 patients with AMI‐CS who underwent primary percutaneous coronary intervention and compared the outcomes of VA‐ECMO+IABP (n=2964) to VA‐ECMO alone (n=851). Though patients in the VA‐ECMO+IABP group were younger, they were more likely to have higher rates of comorbidities including hypertension, dyslipidemia, diabetes, and atrial fibrillation. IABP was more likely to be used in hospitals with teaching status, more hospital beds, and availability of cardiac surgery. The authors concluded that patients managed with VA‐ECMO+IABP demonstrated significantly lower in‐hospital (adjusted odds ratio [OR], 0.47 [95% CI, 0.38–0.59]), 7‐day (adjusted OR, 0.41 [95% CI, 0.33–0.51]), and 30‐day mortality (adjusted OR, 0.30 [95% CI, 0.25–0.37]) in comparison to those managed with VA‐ECMO alone. These findings align with the results from a meta‐analysis that noted the benefit of IABP combined with VA‐ECMO in patients with AMI‐CS.6 We would like to commend the authors for their work on addressing an important question using the largest cohort to date. However, there are certain points that merit discussion (Figure).First, as the authors mention in the Limitations section, the information pertaining to the detailed timing of CS, IABP placement and ECMO placement were not available. Early use of VA‐ECMO in patients with AMI‐CS has been shown to be associated with a significant survival benefit.8 Delaying the initiation of mechanical circulatory support may be deleterious, because prolonged microcirculatory dysfunction leads to irreversible end‐organ injury, rendering any subsequent hemodynamic intervention futile.9 The results of the ongoing ECMO‐CS (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock),10 a multicenter trial of patients with AMI‐CS randomized to early ECMO versus standard of care, are eagerly awaited to understand the timing and role of VA‐ECMO in CS better. Furthermore, among the patients requiring VA‐ECMO, early unloading of the LV appears to be associated with increased success of weaning and reduced short‐term mortality. In a meta‐analysis by Al‐Fares et al,8 early (<12 hours) VA‐ECMO+IABP (7 studies) was associated with a reduced short‐term mortality (risk ratio [RR], 0.80 [95% CI, 0.68–0.94]). For late (>12 hours and beyond) unloading with IABP, only 1 study met the inclusion criteria in this meta‐analysis. Therefore, further studies are needed to understand the timing of unloading the LV with IABP in patients on VA‐ECMO with AMI‐CS. Similarly, in a multicenter study by Schrage et al,11 early left ventricular unloading with Impella was defined as <2 hours, which was associated with a decrease in mortality among patients with CS as compared with late left ventricular unloading. Left ventricular distension is an increasingly appreciated nuance of VA‐ECMO support. Therefore, it is of utmost importance to recognize the triggers of left ventricular unloading in patients on VA‐ECMO including (1) an elevated pulmonary capillary wedge pressure, (2) an aortic valve that remains closed throughout the cycle, (3) persistent pulmonary edema on chest x‐ray film, (4) a distended hypocontractile LV, and (5) refractory ventricular arrhythmias.12 Nishi et al7 illustrate that in‐hospital mortality was higher in patients who were started on IABP with subsequent VA‐ECMO than the others, including those who started on VA‐ECMO with subsequent IABP and those who had VA‐ECMO+IABP on the same day. Early IABP placement followed by escalation to VA‐ECMO may demonstrate a rapidly worsening phenotype portending worse outcomes, whereas a patient started on VA‐ECMO with subsequent IABP implantation for the purpose of left ventricular unloading may denote delayed myocardial recovery and is reported to have a better prognosis.13Second, this study by Nishi et al7 was different from the previous study from the Japanese inpatient database by Aso et al,14 in that they included patients with cardiac arrest (CA) at the time of admission, which were missing in the latter. Around 17% of the patients had cardiac arrest at the time of admission. There were no significant differences in the percentage of patients with CA between the VA‐ECMO+IABP versus VA‐ECMO alone groups. It is well established that the combination of CS and CA is associated with higher rates of in‐hospital mortality, and acute noncardiac organ failure in both ST‐segment–elevation15 and non–ST‐segment–elevation16 AMI admissions as compared with CS or CA alone. In patients with CA, VA‐ECMO–facilitated cardiopulmonary resuscitation can be used to restore circulation, prevent end‐organ damage, and facilitate percutaneous coronary intervention.17 Unlike in CS, where the mechanical circulatory support devices serve to support the circulatory function, VA‐ECMO in CA is used to maintain cerebral and other vital organ perfusion despite the lack of return of spontaneous circulation. One of the limitations of the present study was that it could not be determined if the VA‐ECMO device was placed as a part of the facilitated resuscitation protocol or to support circulatory function. It is important to determine that, because the phenotype of combined AMI‐CS+CA is different from CS alone. Encouragingly, the authors demonstrated improved survival with combined VA‐ECMO+IABP in both patients with and without CA.Lastly, it is important to mention about the unique end points in cardiac critical care especially in patients with CS. The authors mention that the risk of mechanical ventilation use was lower in patients in the VA‐ECMO+IABP group (RR, 0.49 [95% CI, 0.45–0.53]). This is a significant pertinent point. A previous study18 has shown that use of IABP with VA‐ECMO was independently associated with a lower frequency of hydrostatic pulmonary edema and more days off the mechanical ventilation. An additional unique and important end point includes acute noncardiac organ failure. Acute organ failure in AMI‐CS is presumed to be secondary to systemic inflammation and microcirculatory abnormalities in addition to primary pump failure.19 Presence of multiorgan failure in AMI‐CS is independently associated with higher in‐hospital mortality and greater resource use.20 Given that this data set did not have information related to the noncardiac organ failure, the authors could not measure this important end point. Further studies in acute cardiovascular care, and specifically CS, should consider these unique end points pertinent to critical care cardiology, in addition to traditional metrics used in cardiovascular medicine.Although limited by the caveats mentioned above, this study by Nishi et al supports the use of IABP for left ventricular unloading in AMI‐CS being treated with VA‐ECMO. However, these results cannot be extrapolated to other causes of CS.6 The results from the observational studies point to a need for a randomized trial evaluating the outcomes of VA‐ECMO+IABP in patients with AMI‐CS to better define the management practice in this acutely ill patient population.DisclosuresNone.Download figureDownload PowerPointFigure 1. Current state of the evidence for LV unloading in VA‐ECMO for AMI‐CS.AMI indicates acute myocardial infarction; CA, cardiac arrest; CS, cardiogenic shock; LV, left ventricular; and VA‐ECMO, veno‐arterial extracorporeal membrane oxygenation.Footnotes* Correspondence to: Saraschandra Vallabhajosyula, MD, MSc, Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, 306 Westwood Avenue, Suite 401, High Point, NC 27262. E‐mail: [email protected]eduThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 3.See Article by Nishi et al.REFERENCES1 Samsky MD, Morrow DA, Proudfoot AG, Hochman JS, Thiele H, Rao SV. Cardiogenic shock after acute myocardial infarction: a review. JAMA. 2021; 326:1840–1850. doi: 10.1001/jama.2021.18323CrossrefMedlineGoogle Scholar2 Vallabhajosyula S, Bhopalwala HM, Sundaragiri PR, Dewaswala N, Cheungpasitporn W, Doshi R, Prasad A, Sandhu GS, Jaffe AS, Bell MR, et al. Cardiogenic shock complicating non‐ST‐segment elevation myocardial infarction: an 18‐year study. Am Heart J. 2022; 244:54–65. doi: 10.1016/j.ahj.2021.11.002CrossrefMedlineGoogle Scholar3 Vallabhajosyula S, Dewaswala N, Sundaragiri PR, Bhopalwala HM, Cheungpasitporn W, Doshi R, Miller PE, Bell MR, Singh M. 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Optimal strategy and timing of left ventricular venting during veno‐arterial extracorporeal life support for adults in cardiogenic shock: a systematic review and meta‐analysis. Circ Heart Fail. 2019; 12:e006486. doi: 10.1161/CIRCHEARTFAILURE.119.006486LinkGoogle Scholar9 Wong ASK, Sin SWC. Short‐term mechanical circulatory support (intra‐aortic balloon pump, Impella, extracorporeal membrane oxygenation, TandemHeart): a review. Ann Transl Med. 2020; 8:829. doi: 10.21037/atm‐20‐2171CrossrefMedlineGoogle Scholar10 Ostadal P, Rokyta R, Kruger A, Vondrakova D, Janotka M, Smíd O, Smalcova J, Hromadka M, Linhart A, Bělohlávek J. Extra corporeal membrane oxygenation in the therapy of cardiogenic shock (ECMO‐CS): rationale and design of the multicenter randomized trial. Eur J Heart Fail. 2017; 19(suppl 2):124–127. doi: 10.1002/ejhf.857CrossrefMedlineGoogle Scholar11 Schrage B, Becher PM, Bernhardt A, Bezerra H, Blankenberg S, Brunner S, Colson P, Cudemus Deseda G, Dabboura S, Eckner D, et al. 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ESC Heart Fail. 2021; 8:2259–2269. doi: 10.1002/ehf2.13321CrossrefMedlineGoogle Scholar17 Yannopoulos D, Bartos JA, Aufderheide TP, Callaway CW, Deo R, Garcia S, Halperin HR, Kern KB, Kudenchuk PJ, Neumar RW, et al.; American Heart Association Emergency Cardiovascular Care Committee . The evolving role of the cardiac catheterization laboratory in the management of patients with out‐of‐hospital cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2019; 139:e530–e552. doi: 10.1161/CIR.0000000000000630LinkGoogle Scholar18 Bréchot N, Demondion P, Santi F, Lebreton G, Pham T, Dalakidis A, Gambotti L, Luyt C‐E, Schmidt M, Hekimian G, et al. Intra‐aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial‐extracorporeal membrane oxygenation. Eur Heart J Acute Cardiovasc Care. 2018; 7:62–69. doi: 10.1177/2048872617711169CrossrefMedlineGoogle Scholar19 den Uil CA, Lagrand WK, van der Ent M, Jewbali LS, Cheng JM, Spronk PE, Simoons ML. Impaired microcirculation predicts poor outcome of patients with acute myocardial infarction complicated by cardiogenic shock. Eur Heart J. 2010; 31:3032–3039. doi: 10.1093/eurheartj/ehq324CrossrefMedlineGoogle Scholar20 Vallabhajosyula S, Dunlay SM, Prasad A, Kashani K, Sakhuja A, Gersh BJ, Jaffe AS, Holmes DR, Barsness GW. Acute noncardiac organ failure in acute myocardial infarction with cardiogenic shock. J Am Coll Cardiol. 2019; 73:1781–1791. doi: 10.1016/j.jacc.2019.01.053CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesOutcomes of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra‐Aortic Balloon Pumping for Treatment of Acute Myocardial Infarction Complicated by Cardiogenic ShockTakeshi Nishi, et al. Journal of the American Heart Association. 2022;11 April 5, 2022Vol 11, Issue 7Article InformationMetrics Copyright © 2022 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.122.025274PMID: 35377158 Originally publishedApril 4, 2022 Keywordscardiogenic shockEditorialsintra‐aortic balloon pumpleft ventricular unloadingveno‐arterial extracorporeal membrane oxygenationPDF download SubjectsMyocardial Infarction

Early outcomes of Intra-Aortic Balloon Pump in Patients Undergoing Coronary Artery Bypass Grafting (CABG) Surgery

Background: Care of heart patients especially after coronary artery bypass graft (CABG) surgery can be difficult to manage especially in postoperative phase due to decreased cardiac output. Inotropes used to increase cardiac output during the peri or postoperative may cause harmful effects. Mechanical circulatory support devices, such as an intra-aortic balloon pump can be beneficial in such patients. Objective: To compare early outcomes of Intra-Aortic Balloon Pump (IABP) in Patients Undergoing Coronary Artery Bypass Grafting (CABG) Surgery Methods: Systematic random samples of 134 patients were registered from the department of cardiac surgery of Punjab Institute of Cardiology (PIC), Lahore undergone open heart surgery from December 2019 to May 2020. High-risk patients with hemodynamically stable undergoing scheduled CABG were included. The patients were divided into two groups. All information including gender and age were obtained using a structured questionnaire. Death and other complications were compared between two groups. Data was entered and analyzed using SPSS. Statistical test like chi- square and Independent t-tests were applied to obtain the required results and percentages. Results: Total 134 patients enrolled and equally divided into two groups. Group A (with IABP) have mean age was 47.58± 2.0 compared with Group B (without IABP) mean age 48.43± 4.31.There were 79(63.2%) males and 46(36.8%) were females enrolled. Hypertension, diabetes mellitus, smoking, Prior CVA, recent AMI and congestive heart failure remained statistically insignificant as p-value &gt; 0.05. The duration of IABP, respiratory failure, renal dysfunction and length of ICU stay showed statistically significant p-value &lt; 0.05. Reoperation for bleeding, acute AMI, pneumonia, stroke, wound infection and surgical mortality are statistically insignificant as pvalue &gt; 0.05. Conclusion: In high-risk patients of coronary artery bypass graft, early implantation of an intra-aortic balloon pump improves the outcomes by reducing ICU stay and death; increased post-insertion creatinine levels have been proven to be an indication of approaching mortality. Keywords: Intra-aortic balloon pump, Coronary artery bypass graft, Creatinine levels, Low Cardiac Output Syndrome

ANMCO POSITION PAPER: Role of intra-aortic balloon pump in patients with acute advanced heart failure and cardiogenic shock.

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.

Complications and outcome of the long-term use of the intra-aortic balloon pump in patients with end-stage heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background Intra-aortic balloon pump (IABP) can be used as circulatory support in order to stabilize haemodynamically compromised patients as either a bridge to therapy or to further mechanical support. Based on the current literature its use should be limited to up to two weeks and there are not enough data regarding its long term use’s efficacy and possible complications. Purpose To review the possible complications of the long-term use of IABP Methods We restrospectively analysed the data from 24 consecutive patients with end-stage heart failure (ESHF) who received long-term IABP support and recorded the complications during their hospitalization as well as their outcome. Results 24 patients (14 male and 10 female) were included. In 5 of them ESHF was attributed to ischemic cardiomyopathy and the in 19 to dilated cardiomyopathy. Their mean age was 45.6+/-14 years. The mean duration of IABP support was 70.2 days (minimum 30days maximum 192 days). The mean ejection fraction (EF) was 20%. Regarding the pharmacological therapy, 12/24 patients were on dobutamine, 4/24 on dobutamine and milrinone and 8/24 on dobutamine and noradrenaline. Regarding the clinical course of these patients, 7/24 underwent heart transplantation, 2/24 managed to wean from IABP, 5/24 received left lentrivular assist device (LVAD), 6/24 received biventricular assist veice (BiVAD) and 4/24 died. In terms of complications they were recorded as following : infection 7/24, bleeding 3/24, thrombosis 4/24, heparin-induced thrombocytopenia(HIT) 5/24, hematoma 4/24, ischemia 0/24 and rupture 1/24. Conclusions   Although not indicated by the current guidelines, long term IABP can be used as a relatively safe  circulatory support method.

LEVOSEMINDAN VERSUS INTRA-AORTIC BALLOON PUMP IN LOW EJECTION FRACTION CABG PATIENTS

Background: Preoperative left ventricular dysfunction is an independent risk factor for perioperative mortality and morbidity and is also associated with postoperative low cardiac output syndrome. IABP improved outcomes in high-risk cardiac patients. However, installation of the balloon has many disadvantages. Recently, a new drug named Levosimendan is commonly used as an inotropic support. it does not increase oxygen demand of myocardium.Aim of the work: The purpose of our study was to compare the efficiency of levosimendan versus intra-aortic balloon pump in patients with poor left ventricular function undergoing coronary artery bypass grafting (CABG) with ejection fraction less than 35%.Patients and Methods: sixty patients were randomized into 2 groups, according to the treatment they received - either levosimendan (Group A) or intra-aortic balloon counter pulsation (Group B). and compared with respect to The use of inotropic drugs, weaning from CPB, Hemodynamics, transfusion requirements, ICU stay, hospital stay and in-hospital mortality.Results: There were no differences in preoperative characteristics including patients’ age, sex, BMI, and comorbidities. The Levosemindan group had reduced transfusion requirements and shorter ICU stay as compared to IABP group.Conclusion: levosimendan infusion after induction of anesthesia is a good choice with an acceptable option in comparison to IABP. The use of levosimendan in high-risk cardiac patients is comparable to IABP in improving hemodynamics during and after conventional on-pump CABG and results in a shorter ICU stay.

Trends in the Use of Cardiac Assist Devices in Heart Failure Patients with Cardiogenic Shock

Introduction Currently, the most frequently used mechanical assist device for cardiogenic shock is the intra-aortic balloon pump (IABP). IABPSHOCK II trial in 2012 failed to show any benefits, therefore, the use of an IABP was downgraded to a Class IIA recommendation in the 2013 AHA/ACC guidelines. With recent innovations, the use of percutaneous ventricular assist devices (pVADs) is becoming common. We have looked at the recent trends in the use of pVADS and IABP in patients of heart failure with cardiogenic shock. Methods Data from national inpatient from the year 2002 to 2016 was used for temporal trends. ICD 9 and ICD 10 codes were used to identify patients of heart failure with cardiogenic shock and the use of heart assist devices. Pearson Chi-square was used for categorical variables and the t-test was used for continuous variables. Results We identified 319, 696 patient encounters. Median age was 68 (interquartile range 58-78) years. Mortality was very high at 27.0% (86,360). 30.8% (98,570) patients underwent left heart catheterization. Percutaneous coronary intervention (PCI) was done in 14.4% (45,914) patients. In 4.4%(13,977) external Left ventricular assist device (LVAD), in 3.0% (9525) percutaneous Ventricular assist devices (pVADs), in 20.3% (64,807) intra-aortic balloon pump (IABP) and in 9.3 (29,861) vasopressors were used. There has been an increasing trend in the use of pVADs while a decreasing trend was noticed in the use of IABP. Vasopressin and LVADs have shown a variable trend (Figure). Conclusion Use of IABP has decreased while the use of pVADs has increased over the years in patients with cardiogenic shock.