Intra-aortic Counterpulsation Research Articles

Extracorporeal Blood Purification with CytoSorb in 359 Critically Ill Patients

Introduction: Critically ill patients with inflammatory dysregulation and organ disfunction may benefit from blood purification, although the use of this technique has not been described in large case series. We evaluated clinical outcomes and survival in high-risk intensive care unit (ICU) patients who underwent extracorporeal blood purification. Methods: 359 consecutive ICU patients treated with CytoSorb were included. Results: Main admission diagnoses were 120 (34%) refractory cardiac arrest under mechanical chest compression; 101 (28%) profound cardiogenic shock; 81 (23%) post-cardiotomy cardiogenic shock; and 37 (10%) respiratory failure. Fifteen patients (4%) were positive for SARS-CoV-2 infection. We observed 49% 30-day mortality, 57% ICU mortality, and 62% hospital mortality, all lower than the 71% mortality predicted by SAPS II and 68% predicted by SOFA score. Parameters of shock and organ failure, above all vasoactive inotropic score, reduced during CytoSorb treatment. Multivariable analysis identified SAPS II, lactate dehydrogenase, ICU stay duration, vasoactive inotropic score, lactates, intra-aortic counterpulsation on top of VA-ECMO, and total bilirubin as predictors of mortality. No CytoSorb-related complications occurred. Conclusion: CytoSorb treatment was effective in reducing laboratory parameters of shock and vasoactive inotropic score with possible survival implications in a large population of critically ill patients.

P56: Morbidity and Mortality Associated with Intra-Aortic Counterpulsation Balloon Pump Use

Background: Postoperative acute limb ischemia (pALI) is a vascular emergency better prevented than treated. Knowledge of the predisposing factors is vital to prevention and early recognition. In this study, we examined the predictors and risk of 30-day postoperative mortality of pALI among patients who underwent open-heart surgery. Methods: We retrospectively analyzed data collected at a single university hospital as part of the Society of Thoracic Surgeons National Adult Cardiac Surgery database between January 2006 and January 2018. The primary outcome was pALI (coded in STS as CVaLbIsc) defined as any ischemic event of the arterial system of either upper or lower limbs. For this analysis transcatheter procedure and entries with the missing outcome variable were excluded. The final sample was divided into 2 groups based on the presence of pALI or not. Logistics regression model was used to assess for association between pALI and the preop variable. KM curves were plotted to compare survival probability between the 2 groups. Results: Among the 5231 records included in this analysis, there were 60 (1.15%) cases of pALI. Multivariate regression model adjusting for known risk factors of acute limb ischemia showed preop IABP use (OR 4.16(95%CI 2.22 - 7.80), p=<.0001); body surface area (OR 0.19 (95%CI 0.07 - 0.52), p= 0.001); emergent/urgent procedures (OR 2.57 (95%CI 1.32 - 4.98), p=0.005; history of PVD (OR 4.89 (95%CI 2.83 - 8.43), p=<.0001); preop IV steroid use (OR 3.07 (95%CI 1.32 - 7.16), p=0.009; history of infective endocarditis (OR 3.66 (95%CI 1.61 - 8.29), p=0.002; Cardiogenic shock (OR 2.86 (95%CI 1.41 - 5.78), p=0.003) are independent predictors of pALI. ROC curve AUC of final model= 0.83. Conclusion: A knowledge of the above risk factors may help identify at-risk individuals that may benefit from perioperative limb tissue oxygenation or perfusion monitoring thereby facilitating prompt diagnosis and intervention.

Infarktbedingter kardiogener Schock

Cardiogenic shock as a complication of myocardial infarction (5-10%) increases the mortality of uncomplicated myocardial infarction from less than 10% to 40%. This is due to the development of multiple organ dysfunction syndrome triggered by the extensive shock-induced impairment of organ perfusion. Therefore, guideline-based treatment should not only be restricted to reopening of the occluded coronary artery and management of complications of the infarction: important for survival are also guideline-driven optimization of organ perfusion by inotropic and vasoactive substances and, with well-defined indications, by temporary mechanical circulatory support but not by intra-aortic counterpulsation. Equally important, however, are shock-specific intensive care measures to prevent or attenuate organ dysfunction, such as lung protective ventilation in cases where ventilation is obligatory.

Intra-Aortic Balloon Pumping in Acute Decompensated Heart Failure With Hypoperfusion: From Pathophysiology to Clinical Practice.

Trials on intra-aortic balloon pump (IABP) use in cardiogenic shock related to acute myocardial infarction have shown disappointing results. The role of IABP in cardiogenic shock treatment remains unclear, and new (potentially more potent) mechanical circulatory supports with arguably larger device profile are emerging. A reappraisal of the physiological premises of intra-aortic counterpulsation may underpin the rationale to maintain IABP as a valuable therapeutic option for patients with acute decompensated heart failure and tissue hypoperfusion. Several pathophysiological features differ between myocardial infarction- and acute decompensated heart failure-related hypoperfusion, encompassing cardiogenic shock severity, filling status, systemic vascular resistances rise, and adaptation to chronic (if preexisting) left ventricular dysfunction. IABP combines a more substantial effect on left ventricular afterload with a modest increase in cardiac output and would therefore be most suitable in clinical scenarios characterized by a disproportionate increase in afterload without profound hemodynamic compromise. The acute decompensated heart failure syndrome is characterized by exquisite afterload-sensitivity of cardiac output and may be an ideal setting for counterpulsation. Several hemodynamic variables have been shown to predict response to IABP within this scenario, potentially guiding appropriate patient selection. Finally, acute decompensated heart failure with hypoperfusion may frequently represent an end stage in the heart failure history: IABP may provide sufficient hemodynamic support and prompt end-organ function recovery in view of more definitive heart replacement therapies while preserving ambulation when used with a transaxillary approach.

Relationship between Augmentation Index and Wall Thickening Fraction during Hypotension in an Animal Model of Myocardial Ischemia-Reperfusion and Heart Failure.

Non-invasive indices to evaluate left ventricular changes during ischemic heart failure are needed to quantify the myocardial impairment and the effectiveness of therapeutic manoeuvres. The aims of this work were to calculate the Wall Thickening Fraction (WTF) and the Augmentation Index (AIx) and to assess the relationship between WTF and AIx using data obtained from an animal model with heart failure followed by a myocardial ischemia stage and a reperfusion stage. Nine Corriedale sheep that had been monitored for 10 minutes during a basal stage underwent 5-minute myocardial ischemia, followed by 60-minute reperfusion. Seven of them were subjected to an induced heart failure through an overdose of halothane, two of which were treated with intra-aortic counterpulsation during the reperfusion stage. The remaining two animals were monitored during their ischemia-reperfusion stage. Data obtained in the 5 animals suffering from heart failure followed by myocardial ischemia showed that: a) heart failure induction determined decrease in cardiac output, cardiac index and systolic and diastolic aortic pressure (AoP) with respect to their basal values (p<0.05), b) myocardial ischemia decreased the WTF compared with basal and induced heart failure values (p<0.05), c) during the reperfusion stage accompanied by induced heart failure, WTF increased with respect to values observed during the ischemia induction stage (p<0.05); nevertheless, basal values were not recovered after reperfusion (p<0.05). During this 60-minute stage, systolic and diastolic AoP values were lower (p<0.05) than those at the basal stage. AIx and WTF values calculated from synchronically recorded values of aortic pressure and left ventricular wall thickness during the reperfusion stage in all animals (n = 9) showed a negative correlation (p<0.05). Analysed data provided evidence of a negative relationship between a left ventricular index of myocardial function and an arterial index obtained from AoP waves.

Temporary Circulatory Support With Ventricular Assist Devices: Update on Surgical and Percutaneous Strategies.

The available platforms for temporary circulatory support (TCS) have expanded to include impeller technologies in addition to the traditional approaches with centrifugal pumps and intra-aortic counterpulsation. We review the evidence for competing technologies, relative risk, and benefit of individual TCS platforms and provide a consensus opinion in the context of our institutional experience. Trans-aortic axial flow devices (Impella) have significantly impacted the support of patients with cardiogenic shock. Despite the absence of prospective randomized data, the use of both percutaneous and surgical Impella devices is ubiquitous among heart failure centers and rapidly evolving. Extracorporeal centrifugal pumps remain the technology of last resort. Despite the increasing use of new TCS platforms, there is little empirical evidence that outcomes have been impacted. Increasingly, systems of care-rather than technology-are seen as the more important variable in the management of patients with cardiogenic shock.

Evaluation of risk factors for adverse outcome in extracorporeal membrane oxygenation-supported elderly postcardiotomy patients.

Recently extracorporeal membrane oxygenation is becoming the commonly used mechanical assist device for the treatment of severe cardiogenic shock in postcardiotomy patients. Evaluation of risk factors of negative outcome would be beneficial in decision-making in the elderly patient population. This was a retrospective single-centre analysis of elderly patients who underwent extracorporeal membrane oxygenation treatment for refractory cardiogenic shock in a tertiary care centre. Demographic data, comorbidities and perioperative parameters were collected to evaluate their impact on the outcome of extracorporeal membrane oxygenation treatment in this patient group. Logistic regression analysis of the variables was performed to identify factors predicting an adverse outcome. Forty consecutive elderly patients underwent extracorporeal membrane oxygenation treatment during the study period. The mean age was 76.7 ± 3.8 years, 27 (68%) were male. The mean Survival after Veno-Arterial extracorporeal membrane oxygenation score before initiating extracorporeal membrane oxygenation support was - 11 ± 6. Intra-aortic counterpulsation was used as the first-line mechanical support in 31 (77%) patients. The mean duration of extracorporeal membrane oxygenation support was 172 ± 128 hours. Twenty-four patients (56%) were successfully weaned from extracorporeal membrane oxygenation, and 8 (20%) survived to hospital discharge. Lactate level before extracorporeal membrane oxygenation initiation was the only predictor of unfavourable outcome in multivariate analysis (p < 0.05). High lactate level before initiation of extracorporeal membrane oxygenation was the most important prognostic values of an unfavourable outcome.

Anemia in patients with high-risk acute coronary syndromes admitted to Intensive Cardiac Care Units.

BackgroundLittle information exists about the role of anemia in patients with acute coronary syndromes (ACS) admitted to Intensive Cardiac Care Units (ICCU). The aim of this study was to assess the prevalence of anemia and its impact on management and outcomes in this clinical setting.MethodsAll consecutive patients admitted to eight different ICCUs with diagnosis of non-ST segment elevation ACS (NSTEACS) were prospectively included. Anemia was defined as hemoglobin < 130 g/L in men and < 120 g/L in women. The association between anemia and mortality or readmission at six months was assessed by the Cox regression method.ResultsA total of 629 patients were included. Mean age was 66.6 years. A total of 197 patients (31.3%) had anemia. Coronary angiography was performed in most patients (96.2%). Patients with anemia were significantly older, with a higher prevalence of comorbidities, poorer left ventricle ejection fraction and higher GRACE score values. Patients with anemia underwent less often coronary angiography, but underwent more often intraaortic counterpulsation, non-invasive mechanical ventilation and renal replacement therapies. Both ICCU and hospital stay were significantly longer in patients with anemia. Both the incidence of mortality (HR = 3.36, 95% CI: 1.43–7.85, P = 0.001) and the incidence of mortality/readmission were significantly higher in patients with anemia (HR = 2.80, 95% CI: 2.03–3.86, P = 0.001). After adjusting for confounders, the association between anemia and mortality/readmission remained significant (P = 0.031).ConclusionsAlmost one of three NSTEACS patients admitted to ICCU had anemia. Most patients underwent coronary angiography. Anemia was independently associated to poorer outcomes at 6 months.

Impact on intra-aortic balloon pump placement technique on cardiac surgical patient outcomes

Introduction Although the use of intra-aortic counterpulsation in cardiogenic shock was recently debated¹, it remains widely used device for the treatment of cardiac failure. The aim of our study was to evaluate intra-aortic balloon pump (IABP) placement technique related morbidity in cardiac surgical patient population. Methods Single center retrospective review of 424 cardiac surgical patients treated with intra-aortic counter-pulsation between January 1, 2013 and April 30, 2019 in a tertiary care center. Patient outcomes, procedure related morbidity and IABP insertion technical characteristics were evaluated (elective vs urgent, sheathed vs sheathless, ideal balloon tip position vs malposition). According to tip position patients were divided into three groups: good (at T2-T4 vertebrae), malposition (T5-T6), severe malposition (at T7 or below). Results Median patient age was 67 [Interquartile range (IQR), 59 to 75 years], 307 (72.4%) were male. Median EuroSCORE II was 4.4 [IQR, 2.4 to 10.5], median LVEF was 35 [IQR, 28 to 50]. Indications for IABP treatment were: cardiac failure or angina treatment before surgery in 45 (10.6%) patients, prophylactic use in high risk 178 (42.0%) patients, hemodynamically unstable before CPB in 5 (1.2%), hemodynamically unstable during off-pump CABG in 11 (2.6%), facilitate weaning from CPB in 47 patients (11.1%) low cardiac output following surgery in 137 (32.3%), weaning from ECMO in 1 (0.2%). Three hundred forty nine patients (82.3 %) survived to hospital discharge. In-hospital mortality was 5.1% in elective IABP placement group vs 26.8% in urgent IABP implementation group (p Discussion Elective balloon placement was associated with lower morbidity in cardiac surgical patients. Sheathed insertion showed a tendency of higher rate of vascular complications. Suboptimal IABP tip position was not associated with adverse outcome.

Coronary artery bypass surgery in patients with chronic brain hypoperfusion.

Cerebrovascular disease (CVD) is a risk factor of stroke and cerebral hypoperfusion is one of the underlying mechanisms. We hypothesized that coronary artery bypass grafting (CABG) can be performed at an acceptable risk for such patients without concomitant surgery for CVD. Carotid echo was carried out for 538 consecutive patients undergoing isolated CABG between 2005 and 2016. Magnetic resonance image/angiography (MRI/A) for neck and brain was performed for 288 patients (stenoses ≥50% in echo were basically included). Patients with multiple severe stenoses (≥70%) and/or occlusion in carotid and/or vertebral systems associated with contra-lateral carotid and/or Willis circle lesions (reduced collateral flow) on MRI/A (N.=43) were investigated. Whenever possible, single photon emission computed tomography (SPECT, N.=20) with or without acetazolamide challenge was performed. Off-pump CABG was used in all patients. Systolic arterial pressure was maintained ≥100 mmHg or ≥90 mmHg with intra-aortic counter-pulsation. Patients were followed up for one year and MRI was performed. Hypoperfusion and reduced cerebrovascular reserve were observed in 90.0% and 88.9% respectively in patients underwent SPECT. There was one postoperative stroke and no mortality. MRI (N.=32) revealed no new stroke, however, five other patients experienced strokes during follow-up period. In patients without the CVD, there was one stroke in the study period, which was seen postoperatively. CABG can be performed at an acceptable risk in patients with brain hypoperfusion. However, these patients suffered high stroke incidence during the follow-up. It is therefore, important to identify those patients preoperatively to plan and implement an appropriate treatment regime.

Mortality in patients with cardiogenic shock treated with the Impella CP microaxial pump for isolated left ventricular failure.

Cardiogenic shock is still associated with high mortality rates of around 50%. Intra-aortic counterpulsation had been frequently used in cardiogenic shock, but was previously found to provide no mortality benefit. We investigated the effect of an interdisciplinary and multiprofessional routine strategy of early invasive haemodynamic support in combination with complete revascularization in patients with cardiogenic shock before admission to our intensive care unit. We analysed all cardiogenic shock patients (mean age 62±13 years) presenting at our institution between 2013 and mid 2016, who received an Impella CP microaxial pump for isolated left ventricle support (n=61). Sixty-one per cent (n=37) had been resuscitated before Impella insertion. Overall mortality was 48% (n=29/61) at 30 days. Thirty-day mortality was higher in resuscitated patients (resuscitated: 65% (n=24/37); non-resuscitated: 21% (n=5/24)). When applying the inclusion/exclusion criteria of the SHOCK-II trial, eligible patients (n=25) had a markedly lower mortality (24% (n=6/25) at 30 days) compared with the published trial (~40% in both arms). The observed mortality of SHOCK-II-like patients in the registry was also lower compared with their predicted mortality using IABP-Shock II score (49%) and CardShock score (36%). The results of this registry suggest that using a standardized protocol including early active haemodynamic support with Impella CP in cardiogenic shock in patients with isolated left ventricle failure may be associated with improved outcomes and lower than previously reported or predicted mortality rates. Pre-implantation cardiac arrest critically influences observed mortality. The results support the case for a randomized trial.

Preoperative Intra-Aortic Counterpulsation in Cardiac Surgery: Insights From a Retrospective Series of 588 Consecutive High-Risk Patients

To support a rational use of preoperative intra-aortic balloon pump (IABP) in cardiac surgery. Retrospective, observational study. Single university hospital. The study included 588 (mean age 68.5 ± 9.6 yr) consecutive patients who received IABP before cardiac surgery from 1999 to 2016. Coronary surgery was performed in 573 (97.4%) cases. IABP indications were prophylaxis (n = 147), unstable angina (n = 239), and rapid worsening of hemodynamics (n = 202). Baseline characteristics of patients were analyzed with multivariable methods. Comparison of outcomes postsurgery between 74 patients undergoing IABP because of left main coronary artery disease (LMCAD) (stenosis ≥ 50%) and a new series of 1,360 patients experiencing LMCAD but who did not receive an IABP using propensity-score matching. Throughout the study period, the rate of IABP use for prophylaxis and unstable angina increased (p = 0.0029) despite reduction in patient surgical risk (p = 0.0051). Early period of surgery (p = 0.032), rapid worsening of hemodynamics in the operating room (p = 0.0029), renal impairment (p < 0.0001), and ventilation before surgery (p = 0.0032) were predictors of in-hospital mortality. The cumulative rate of IABP-related complications was 6.8%. Current smoking (p = 0.025) and the use of a 9 Fr catheter (p = 0.0017) were predictors of IABP-related vascular complications. No difference was found regarding outcomes postsurgery for 43 pairs of IABP/non-IABP matched patients with LMCAD, even though preoperative IABP was associated with an increased use of bilateral internal thoracic artery grafting. Preoperative use of IABP in cardiac surgery was shown in this study to be safe, even for high-risk patients. LMCAD is not by itself a sufficient indication for prophylactic IABP.

Mechanical chest compressions in the coronary catheterization laboratory to facilitate coronary intervention and survival in patients requiring prolonged resuscitation efforts.

BackgroundResuscitation after cardiac arrest (CA) in the catheterization laboratory (cath-lab) using mechanical chest compressions (CC) during simultaneous percutaneous coronary intervention (PCI) is a strong recommendation in the 2015 European Resuscitation Council (ERC) guidelines. This study aimed at re-evaluating survival to hospital discharge and assess long term outcome in this patient population.MethodsPatients presenting at the cath lab with spontaneous circulation, suffering CA and requiring prolonged mechanical CC during cath lab procedures between 2009 and 2013 were included. Circumstances leading to CA, resuscitation parameters and outcomes were evaluated within this cohort. For comparison, patients needing prolonged manual CC in the cath lab in the pre-mechanical CC era were evaluated. Six-month and one year survival with a mechanical CC treatment strategy from 2004 to 2013 was also evaluated.ResultsThirty-two patients were included between 2009 and 2013 (24 ST-elevation myocardial infarction (STEMI), 4 non-STEMI, 2 planned PCI, 1 angiogram and 1 intra-aortic counter pulsation balloon pump insertion). Twenty were in cardiogenic shock prior to inclusion. Twenty-five were successfully treated with PCI. Median mechanical CC duration for the total cohort (n = 32) was 34 min (range 5–90), for the 15 patients with circulation discharged from the cath-lab, 15 min (range 5–90), and for the eight discharged alive from hospital, 10 min (range 5–52). Twenty-five percent survived with good neurological outcome at hospital discharge. Ten patients treated with manual CC were included with one survivor.DiscussionEighty-seven percent of the patients included in the mechanical CC cohort had their coronary or cardiac intervention performed during mechanical CC with an 80 % success rate. This shows that the use of mechanical CC during an intervention does not seem to impair the interventional result substantially. The survival rate after one year was 87 %.ConclusionsAmong patients suffering CA treated with mechanical CC in the cath-lab, 25 % had a good neurological outcome at hospital discharge compared to 10 % treated with manual CC. Long term survival in patients discharged from hospital is good.

Comparing short versus standard-length balloon for intra-aortic counterpulsation: results from a porcine model of myocardial ischaemia-reperfusion.

We compare a short and a standard-size balloon with same filling volumes to verify the differences in terms of visceral flow, coronary circulation and haemodynamic performance during aortic counterpulsation in an animal model of myocardial ischaemia-reperfusion injury. Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned to have intra-aortic balloon counterpulsation (IABP) with a 40-ml short-balloon (n = 6) or a 40-ml standard-length balloon (n = 6), or to undergo no IABP implantation (controls, n = 6). Haemodynamics and visceral and coronary flows were measured at baseline (t0), at 2 h of ischaemia (t1) and every hour thereafter until 6 h of reperfusion (from tR1 to tR6), respectively. Mesenteric flows increased significantly at tR1 only in the short-balloon group (P < 0.001) and it was constantly higher than in the standard-balloon group regardless of mean arterial pressure, systemic vascular resistance and cardiac output (CO; all, P < 0.001). Renal blood flows were significantly increased during IABP treatment with values constantly and significantly higher in short balloons at any following experimental step (all, P < 0.05). IABP improved CO and coronary blood flow, and reduced afterload, myocardial resistances and myocardial oxygen consumption without differences between the short and the standard-length balloon (all, P > 0.05). The short balloon prevents visceral ischaemia and, compared with the standard-size balloon, it does not lose IABP beneficial cardiac and coronary-related effects. Further studies are warranted to confirm our findings.

Short intra-aortic balloon pump in a swine model of myocardial ischaemia: a proof-of-concept study.

This proof-of-concept study examined the haemodynamic performance as well as the coronary and visceral organ perfusion using a new short balloon for intra-aortic counterpulsation (IABP) in a swine model of myocardial ischaemia. Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned into 3 groups undergoing IABP implantation with a 35-ml short balloon (n = 6), a 40-ml short balloon (n = 6) or no IABP implantation (controls, n = 6). Haemodynamics, and visceral and coronary flows were measured at baseline (t0), at 2 h of ischaemia (t1) and every hour thereafter until 6 h of reperfusion (from tR1 to tR6), respectively. Mesenteric and renal flows increased significantly at tR1 only in the IABP groups (all, P < 0.001) and were significantly higher than controls throughout the reperfusion periods (P < 0.001). Coronary systolic and diastolic blood flows increased only at tR1 in the IABP groups (all, P < 0.001) but were higher than controls at tR1-tR6. The IABP was associated with enhanced haemodynamics compared with controls. No difference was detected using different balloon volumes (all, P > 0.05). The new short balloon significantly increased visceral flow, enhanced haemodynamics and improved coronary circulation during reperfusion following myocardial ischaemia in our experimental model.

Preoperative intra-aortic counterpulsation in high-risk patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials†.

In contrast to the results of previous studies, recent randomized controlled trials (RCTs) failed to show a benefit of prophylactic aortic counterpulsation in high-risk patients undergoing cardiac surgery. The present analysis aims to redefine the effects of this treatment modality in the light of this new evidence. MEDLINE, EMBASE, CENTRAL/CCTR, Google Scholar and reference lists of relevant articles were searched for full-text articles of RCTs in English or German. Assessments for eligibility, relevance, study validity and data extraction were performed by two reviewers independently using prespecified criteria. The primary outcome was hospital mortality. A total of nine eligible RCTs with 1171 patients were identified: 577 patients were treated preoperatively with intra-aortic balloon pump (IABP) and 594 patients served as controls. The pooled odds ratio (OR) for hospital mortality (22 hospital deaths in the intervention arm, 54 in the control group) was 0.381 (95% CI 0.230-0.629; P < 0.001). The pooled analyses of five RCTs including only patients undergoing isolated on-pump coronary artery bypass grafting (n[IABP] = 348, n[control] = 347) also showed a statistically significant improvement in mortality for preoperative IABP implantation (fixed-effects model: OR 0.267, 95% CI 0.129-0.552, P < 0.001). The pooled OR for hospital mortality from two randomized off-pump trials was 0.556 (fixed-effects model, 95% CI 0.207-1.493, P = 0.226). Preoperative aortic counterpulsation was associated with a significant reduction in low cardiac output syndrome (LCOS) in the total population (fixed-effects model: OR 0.330, 95% CI 0.214-0.508, P < 0.001) as well as in the subgroup of CAGB patients (fixed-effects model: OR 0.113, 95% CI 0.056-0.226, P < 0.001), whereas there was no benefit in the off-pump population (fixed-effects model: OR 0.555, 95% CI 0.209-1.474, P = 0.238). Preoperative IABP implantation was associated with a reduction of intensive care unit (ICU) stay in all investigated populations with a greater effect in the total population [fixed-effects model: standard mean difference (SMD) -0.931 ± 0.198, P < 0.001] as well as in the subgroup of CAGB patients (fixed-effects model: SMD -1.240 ± 0.156, P < 0.001), compared with the off-pump group (fixed-effects model: SMD -0.723 ± 0.128, P < 0.001). Despite contradictory results from recent trials, the present study confirms the findings of previous meta-analyses that prophylactic aortic counterpulsation reduces hospital mortality, incidence of LCOS and ICU requirement in high-risk patients undergoing on-pump cardiac surgery. However, owing to small sample sizes and the lack of a clear-cut definition of high-risk patients, an adequately powered, prospective RCT is necessary to find a definite answer to the question, if certain groups of patients undergoing cardiac surgery benefit from a prophylactic IABP insertion.

Influence of intraaortic balloon pump counterpulsation on transesophageal echocardiography derived determinants of diastolic function.

IntroductionIntraaortic balloon pump counterpulsation (IABP) is often used in patients with acute coronary syndrome for its favourable effects on left ventricular (LV) systolic function and coronary perfusion. However, the effects of IABP on LV diastolic function have not been comprehensively investigated. Acute diastolic dysfunction has been linked to increased morbidity and mortality. The aim of this study was to examine the influence of IABP on LV diastolic dysfunction using standard TEE derived parameters.MethodsIntraoperative TEE was performed in 10 patients (mean age 65 ± 11 yrs) undergoing urgent coronary artery bypass graft surgery (CABG), who had received an IABP preoperatively. TEE derived measures of diastolic dysfunction included early to late transmitral Doppler inflow velocity ratio (E/A), deceleration time (Dt), pulmonary venous systolic to diastolic Doppler velocity ratio (S/D), transmitral propagation velocity (Vp), and the ratio of early to late mitral annular tissue Doppler velocities (e’/a’). Statistical analyses included the Wilcoxon Sign-Rank test, and a p<0.05 was considered significant.ResultsTransmitral inflow E/A ratios increased significantly from 0.86 to 1.07 (p < 0.05), while Dt decreased significantly from 218 to 180 ms (p < 0.05) with the use of IABP. Significant increases in Vp (34 cm/s to 43 cm/s; p < 0.05), and e’/a’ (0.58 to 0.71; p < 0.05) suggested a favourable influence of intraaortic counterpulsation on diastolic function.ConclusionThe use of perioperative IABP significantly improves TEE derived parameters of diastolic function consistent with a favourable impact on LV relaxation in cardiac surgery patients undergoing CABG.

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

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

In which patients is transcatheter aortic valve replacement potentially better indicated than surgery for redo aortic valve disease? Long-term results of a 10-year surgical experience

Redo aortic valve replacement procedures have been reduced by the growing practice of trans-catheter aortic valve-in-valve procedures. We analyzed our long-term results of redo aortic valve replacement procedures during a 10-year period in an effort to define subgroups in which trans-catheter aortic valve-in-valve procedures may be better than surgery. From 2002 to 2010, 131 redo aortic valve replacement procedures with at least 18 months of follow-up were prospectively enrolled. Hospital and follow-up outcome of the entire population and of high-risk subgroups were evaluated. Hospital mortality was 2.3%, major re-entry complications were seen in 1.5%, re-exploration for bleeding was seen in 9.2%, perioperative low cardiac output state (ie, low cardiac output syndrome) was seen in 9.9%, stroke was seen in 3.1%, prolonged ventilation was seen in 18.3%, pneumonia was seen in 4.6%, acute renal insufficiency was seen in 11.5%, intra-aortic counterpulsation (intra-aortic balloon pump) was seen in 9.2%, renal replacement therapy was seen in 4.6%, need for transfusions was seen in 60.3%, and permanent pacemaker implantation was seen in 2.3%. One hundred twenty-month actuarial survival, freedom from acute heart failure, reinterventions, stroke, and thromboembolisms were 61.5% ± 8.6%, 62.9% ± 6.9%, 97.8% ± 1.5%, 93.2% ± 3.0%, and 91.2% ± 3.2%, respectively. Patients aged >75 years had similar outcome to younger patients (nonsignificant P for all). Endocarditis resulted in higher hospital mortality (P=.034), low cardiac output state (P<.0001), intra-aortic balloon pump (P<.0001), prolonged ventilation (P=.011), pneumonia (P=.049), acute renal insufficiency (P=.004), lower actuarial survival (log-rank P=.0001), freedom from acute heart failure (P=.002), and re-intervention (P=.003). New York Heart Association functional class IV at admission resulted in a higher incidence of low cardiac output state (P<.0001), intra-aortic balloon pump (P=.0001), prolonged ventilation (P<.0001), pneumonia (P=.015), and a lower actuarial freedom from re-intervention (P=.0001). Higher need for permanent pacemaker implantation (P=.015) and lower freedom from acute heart failure (P=.019) emerged after urgencies/emergencies. Redo aortic valve replacement procedures achieves good results, especially in nonendocarditic or elective cases, and young or New York Heart Association functional class I/II patients. Indeed, endocarditis significantly affects outcome. New York Heart Association functional class IV and nonelective procedures might benefit from trans-catheter aortic valve-in-valve procedures.

Have We Given Up on Intra‐aortic Balloon Counterpulsation in Post–Myocardial Infarction Cardiogenic Shock?

The recently published Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial concluded that intra-aortic counterpulsation (IACP) does not reduce 30-day mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) for whom early revascularization strategy was planned. The study resulted in downgrading IACP in post-AMI CS patients by certain professional organizations like the European Society of Cardiology. Although this is the largest and most important CS study of this decade, it suffers from considerable shortcomings: (1) time intervals from chest-pain onset or AMI recognition to revascularization, enrollment, and IACP initiation are not disclosed; (2) 86.6% of the treatment arm initiated IACP only post-percutaneous coronary intervention (PCI), and 4.3 % did not receive IACP at all; (3) 17.4% of the control arm crossed over to IACP or other mechanical support, mostly due to protocol violations; (4) there is no adjudication of the mortality events; (5) follow-up is limited to 30 days; and (5) both methodology (especially IACP device size) and quality of IACP are not evaluated and documented. Because the study assessed mostly the efficacy and safety of IACP initiated post-PCI, the study conclusions should not be extrapolated to IACP pre-PCI or during PCI in CS. Moreover, IACP had a favorable effect on the mortality of younger patients. Intra-aortic counterpulsation should remain the first line of mechanical circulatory support for the hemodynamically compromised AMI patients with or without CS who are undergoing primary PCI. Early upgrade to more advanced mechanical circulatory support should be considered for selective suitable candidates who remain in refractory CS despite revascularization and IACP.