Intra-aortic Balloon Counterpulsation Group Research Articles

The Preference, Effect, and Prognosis of Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock Patients: A Retrospective Cohort Study.

Backgrounds Intra-aortic balloon counterpulsation is increasingly used in acute myocardial infarction complicated by cardiogenic shock. The aim of this study was to explore the preference, effect, and prognosis of intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock patients. Methods Data of acute myocardial infarction complicated by cardiogenic shock patients at the Fourth Medical Center of PLA General Hospital were collected retrospectively. A propensity score was calculated with a logistic regression which contained clinically meaningful variables and variables selected by Lasso and then used to match the control group. The cumulative incidence curve and Gray's test were employed to analyse the effect and prognosis of intra-aortic balloon counterpulsation on mortality. Results A total of 1962 acute myocardial infarction cases admitted between May 2015 and November 2018 were identified, and 223 cases with acute myocardial infarction complicated by cardiogenic shock were included as the study cohort, which contained 34 cases that received IABP and 189 cases that did not receive IABP. Patients with higher alanine aminotransferase (OR = 1.93, 95% CI 1.29-2.98), higher triglyceride (OR = 3.71, 95% CI 1.87-7.95), and higher blood glucose (OR = 1.08, 95% CI 0.99-1.18) had a higher probability of receiving intra-aortic balloon counterpulsation. In the propensity score matching analysis, 34 cases received intra-aortic balloon counterpulsation and 102 matched controls were included in the comparison. By comparing the cumulative incidence of in-hospital mortality, there was no statistically significant difference between the intra-aortic balloon counterpulsation group and matched control group (P = 0.454). Conclusion The use of intra-aortic balloon counterpulsation may not improve the prognosis of the acute myocardial infarction complicated by cardiogenic shock patients.

Impact of Intra-Aortic Balloon Counterpulsation on Prognosis of Patients with Acute Myocardial Infarction: A Meta-Analysis.

This study aimed to evaluate the impact of intra-aortic balloon counterpulsation (IABP) on the prognosis of patients with acute myocardial infarction (AMI). We identified and included in this study AMI cases treated with IABP from January 1970 to May 2014. For statistical analysis, we utilized RevMan 5.0 software. Fourteen RCTs with a total population of 2538 were included in this study. The in-hospital and 30-day mortality rate in the IABP group was not significantly lower than those in the non-IABP group. Subgroup analysis according to the type of revascularization, OR values of TT subgroup, PCI subgroup, and CABG subgroup were 0.64 (95% CI 0.25-1.61, p = 0.34), 0.85 (95% CI 0.65-1.11, p = 0.23) and 0.46 (95% CI 0.13-1.63, p = 0.23). And OR values of AMI patients in the before and after PCI subgroup were 0.43 (95% CI 0.21-0.91, p = 0.03) and 1.36 (95% CI 0.76-2.41, p = 0.30). The 6-month mortality in the IABP group was not significantly lower than that in the non-IABP group. And OR values of 6-month mortalities of the before and after PCI subgroup were 0.47 (95% CI 0.26-0.86, p = 0.01) and 1.40 (95% CI 0.57-3.45, p = 0.47). IABP did not reduce the in-hospital and 30-day mortality of AMI patients, and did not reduce the 6-month mortality. But IABP used in AMI patients before PCI was associated not only with reduced in-hospital and 30-day mortality, but also reduced 6-month mortality.

Efficacy of intra-aortic balloon counterpulsation in patients with acute myocardial infarction according to the type of revascularization: a meta-analysis

To evaluate the effects of intra-aortic balloon counterpulsation (IABP) on mortality in patients with acute myocardial infarction according to the type of revascularization. Recruited randomized controlled trials of IABP compared with no-IABP controls in acute myocardial infarction patients from January 1970 to May 2015 were searched from Medline, Embase and Cochrane Library, according to inclusion criteria and exclusion criteria. These data were analyzed using the methods recommended by the Cochrane Collaboration's software RevMan 5.0. Revascularization included thrombolytic therapy, percutaneous coronary intervention (PCI), or coronary artery bypass grafting. (1) Eleven randomized controlled trials were enrolled for analysis with 1 102 patients in IABP group, 1 123 in no-IABP control group. (2) Compared with no-IABP control group, IABP could not significantly decrease the in-hospital or 30 day mortality (OR=0.84, 95%CI 0.65-1.09, P=0.20). (3)Compared with no-IABP control group, IABP could not significantly decrease the in-hospital or 30 day mortality in thrombolytic patients(OR=0.64, 95%CI 0.25-1.61, P=0.34), in PCI patients (OR=0.89, 95%CI 0.68-1.18, P=0.42), and in coronary artery bypass grafting patients(OR=0.46, 95%CI 0.13-1.63, P=0.23). (4)The difference reached borderline signiicance between no-IABP control group and IABP group in patients using IABP before PCI(OR=0.47, 95%CI 0.22-1.00, P=0.05), but not in case of after PCI(OR=1.33, 95%CI 0.63-2.79, P=0.45). IABP does not decrease the in-hospital or 30 day mortality of acute myocardial infarction patients who received thrombolytic therapy, PCI, or coronary artery bypass grafting. But IABP might decreases the in-hospital or 30 day mortality in patients when used before PCI.

Extracorporeal life support for cardiogenic shock: influence of concomitant intra-aortic balloon counterpulsation

Intra-aortic balloon counterpulsation (IABP) during extracorporeal life support (ECLS) for cardiogenic shock may improve pulsatility and coronary perfusion, thereby promoting recovery of cardiac function. However, the risks and benefits of IABP during ECLS in real clinical settings have not been evaluated. This study aims to evaluate the effect of IABP on the early outcome of ECLS for cardiogenic shock. We evaluated 253 adult patients (aged 58.8 ± 15.3 [mean ± standard deviation] years, 154 males) undergoing ECLS for cardiogenic shock from January 2005 to August 2012. Of them, 60 patients underwent concomitant IABP (IABP group) and 193 underwent ECLS only (control group). In-hospital outcomes were compared using the inverse probability of treatment weighting based on propensity scores. The indications for ECLS were low cardiac output after cardiac surgery in 118 patients (46.6%), heart failure in 71 (28.1%), acute myocardial infarction in 49 (19.4%) and others in 15 (5.9%). Successful ECLS weaning rate was significantly higher in the IABP group than in the control group (61.7 vs 42.0%, P = 0.008); however, there was no significant difference in in-hospital mortality between the two groups (68.6 vs 72.0%, P = 0.58). After adjustment for propensity of treatment assignment conditional on baseline characteristics, the IABP group showed a decreased risk of weaning failure (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.28-0.92, P = 0.024) but with a similar risk of in-hospital mortality (OR 0.85; 95% CI 0.46-1.60; P = 0.62) compared with the control group. The use of IABP during ECLS increased a successful ECLS weaning rate, but was not translated into improved survival. Studies on larger populations may verify the survival effect of IABP during ECLS.

293 * EXTRACORPOREAL LIFE SUPPORT FOR CARDIOGENIC SHOCK: INFLUENCE OF CONCOMITANT INTRA-AORTIC BALLOON COUNTERPULSATION

OBJECTIVES: Intra-aortic balloon counterpulsation (IABP) during extracorporeal life support (ECLS) for cardiogenic shock may improve pulsatility and coronary perfusion, thereby promoting recovery of cardiac function. However, the risks and benefits of IABP during ECLS in real clinical settings have not been evaluated. This study aims to evaluate the effect of IABP on the early outcome of ECLS for cardiogenic shock. METHODS: We evaluated 253 adult patients (aged 58.8 ± 15.3 [mean ± standard deviation] years, 154 males) undergoing ECLS for cardiogenic shock from January 2005 to August 2012. Of them, 60 patients underwent concomitant IABP (IABP group) and 193 underwent ECLS only (control group). In-hospital outcomes were compared using the inverse probability of treatment weighting based on propensity scores. RESULTS: The indications for ECLS were low cardiac output after cardiac surgery in 118 patients (46.6%), heart failure in 71 (28.1%), acute myocardial infarction in 49 (19.4%) and others in 15 (5.9%). Successful ECLS weaning rate was significantly higher in the IABP group than in the control group (61.7 vs 42.0%, P= 0.008); however, there was no significant difference in in-hospital mortality between the two groups (68.6 vs 72.0%, P= 0.58). After adjustment for propensity of treatment assignment conditional on baseline characteristics, the IABP group showed a decreased risk of weaning failure (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.28–0.92, P= 0.024) but with a similar risk of in-hospital mortality (OR 0.85; 95% CI 0.46–1.60; P= 0.62) compared with the control group. CONCLUSIONS: The use of IABP during ECLS increased a successful ECLS weaning rate, but was not translated into improved survival. Studies on larger populations may verify the survival effect of IABP during ECLS.

Need for Critical Reappraisal of Intra-aortic Balloon Counterpulsation

DESPITE CONSIDERABLE ORGANIZATIONAL, TECHNOlogical, and pharmacological advancements in the treatment of patients with acute ST-segment elevation myocardial infarction (STEMI) and even with percutaneous coronary intervention (PCI), the efficacy of reperfusion is still suboptimal, mortality remains high, and novel therapeutic interventions are needed. Intraaortic balloon counterpulsation (IABC) was first used to treat cardiogenic shock in 1968; since then, it has been used in various clinical conditions to provide mechanical cardiac assistance. Use of IABC is associated with immediate hemodynamic effects leading to increased diastolic pressure, increased coronary perfusion pressure, and reduced left ventricular afterload. In the setting of STEMI, left ventricular unloading by IABC may prevent early infarct extension and ventricular remodeling. Experimental studies have shown that IABC reduces infarct size. Currently, IABC is widely used in patients with STEMI complicated by cardiogenic shock. In addition, IABC has been used as a circulatory support in PCI procedures for patients at high risk for hemodynamic instability such as those with complex coronary lesions, post-MI refractory angina, and severely compromised left ventricular function as well as an intervention in the last remaining vessel and in unprotected left main coronary artery disease. Nevertheless, the issue of IABC use during high-risk PCI procedures or in STEMI remains controversial. The report of the Counterpulsation to Reduce Infarct Size Pre-PCI Acute Myocardial Infarction (CRISP AMI) trial by Patel and colleagues in this issue of JAMA helps to clarify this controversy. CRISP AMI was an open-label, multicenter randomized controlled trial that included 337 patients with STEMI involving the anterior wall who presented within 6 hours of chest pain onset and without cardiogenic shock. Patients were randomly assigned to receive IABC, which was placed prior to PCI and was continued for at least 12 hours, or primary PCI alone. The primary outcome of the trial was infarct size measured by cardiac magnetic resonance imaging. The mean infarct size (estimated a median of 4 days after the onset of symptoms) was 42.1% of the left ventricle in patients assigned to IABC plus PCI and 37.5% of the left ventricle in the patients assigned to PCI alone (P=.06), showing no benefit with IABC. No significant differences between the IABC plus PCI group and the PCI alone group were observed regarding clinical end points. The authors concluded that the routine use of IABC in patients with anterior wall STEMI without cardiogenic shock does not lead to a reduction in infarct size or to an improvement in clinical outcomes at 6 months. Autopsy studies have shown that cardiogenic shock is generally associated with loss of 40% or more of the left ventricular mass, and the association between necrosis of 40% or more and the development of cardiogenic shock has been accepted in the field of cardiology during the last 40 years. Therefore, the finding in the CRISP AMI trial that the mean infarct size estimated by cardiac magnetic resonance imaging was 40% and patients were hemodynamically stable at presentation seems surprising. Moreover, infarct size was recorded after primary PCI, a reperfusion strategy that leads to an average salvage index (proportion of area at risk salvaged by reperfusion) of about 50% according to studies with serial measurements of both the initial area at risk and the final infarct size after reperfusion. Based on the T2weighted imaging obtained from the single magnetic resonance imaging study performed after reperfusion, the authors computed a mean salvage index of 35%. Although the reasons underlying these findings remain largely unclear, possible explanations include an overestimation of infarct size by cardiac magnetic resonance imaging, premature timing of imaging at a point when the recovery of myocardial perfusion is not complete, or dissociation of the link between myocardial necrosis and the development of cardiogenic shock in the contemporary era of STEMI care. Five previous randomized trials have assessed the role of IABC in patients with AMI without cardiogenic shock. However, neither these trials nor the CRISP AMI trial were sufficiently powered for the evaluation of clinical outcomes with IABC, with only 21 deaths among 518 patients in the IABC groups and 21 deaths among 536 patients in the control groups across the studies.

Intra-aortic balloon counterpulsation and delayed revascularization for myocardial infarction and shock in the absence of primary angioplasty: a treatment strategy with or without thrombolysis?

When revascularization facilities are not available, thrombolytic therapy (TT) added to intra-aortic balloon counterpulsation (IABC) has been proposed as initial therapy for the management of patients presenting with postmyocardial infarction (MI) cardiogenic shock, followed by prompt transfer to another institution for revascularization. The use of TT in this setting, however, remains controversial. We reviewed the records of 81 consecutive patients admitted with cardiogenic shock after acute MI and compared the outcomes of patients initially stabilized, including IABC as an adjunct to TT (IABC+TT group, n=40), with those patients initially stabilized with IABC and no TT (IABC group, n=41). The baseline characteristics of the two study groups were similar. The in-hospital and 6-month survival rates were 47.5 and 33.3% in the IABC+TT group versus 43.9 and 31.6% in the IABC group, respectively (NS). Except for mechanical ventilation more frequently required in the IABC group, other outcome measures were similar in both groups. The in-hospital (76.5 vs. 36.5%, P=0.008) and 6-month (60 vs. 25.4%, P=0.01) survival rates were significantly higher in patients who underwent delayed invasive revascularization, than in patients who underwent no invasive revascularization attempt. In patients presenting with acute MI and cardiogenic shock, TT as an adjunct to IABC added no therapeutic benefit when compared with IABC alone. In contrast, the survival of patients was significantly increased by delayed invasive revascularization in both treatment groups. These observations suggest that, when revascularization facilities are not available, stabilization with IABC, followed by prompt transfer for delayed revascularization to a tertiary care hospital, might be the preferred management strategy for patients presenting with post-MI cardiogenic shock.

Thrombolysis and Counterpulsation to Improve Survival in Myocardial Infarction Complicated by Hypotension and Suspected Cardiogenic Shock or Heart Failure: Results of the TACTICS Trial

Sustained hypotension, cardiogenic shock, and heart failure all imply a poor prognosis in acute myocardial infarction (MI). We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation (IABP) to standard treatment for MI, in an international trial among hospitals without primary angioplasty capabilities. We randomized 57 patients with MI complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure to receive either fibrinolytic therapy and IABP or fibrinolysis alone. The primary end point was all-cause mortality at 6 months. In all, IABP was inserted in 27 of 30 assigned patients a median 30 minutes after fibrinolysis began and continued for a median 34 hours. Of the 27 patients assigned to fibrinolysis alone, 9 deteriorated such that IABP was required. The IABP group was at slightly higher risk at baseline, but the incidence of the primary end point did not differ significantly between groups (34% for combined treatment versus 43% for fibrinolysis alone; adjusted P = 0.23). Patients with Killip class III or IV showed a trend toward greater benefit from IABP (6-month mortality 39% for combined therapy versus 80% for fibrinolysis alone; P = 0.05). While early IABP use was not associated with a definitive survival benefit when added to fibrinolysis for patients with MI and hemodynamic compromise in this small trial, its use suggested a possible benefit for patients with the most severe heart failure or hypotension. ABBREVIATED ABSTRACT: We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation to fibrinolytic therapy among 57 patients with acute myocardial infarction complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure. The primary end point, mortality at 6 months, did not differ between groups (34% for combined treatment versus 43% for fibrinolysis alone [n = 27]; adjusted P = 0.23), although patients with Killip class III or IV did show a trend toward greater benefit from IABP (39% for combined therapy versus 80% for fibrinolysis; P = 0.05).

Treatment of post resuscitation myocardial dysfunction: aortic counterpulsation versus dobutamine

Background: Post resuscitation myocardial stunning is well described and recognized as a significant contributor to poor long-term outcome following cardiac arrest. Optimal strategies for treatment have not been determined. Methods: Ten domestic swine (49±3 kg) underwent 15 min of untreated ventricular fibrillation before being successfully resuscitated. Left ventricular systolic and diastolic function was measured at pre-arrest baseline, at 30 min and at 6 h post resuscitation. Five animals were treated immediately after resuscitation with intra-aortic balloon counterpulsation (IABP) and five were given dobutamine (5 mcg/kg per min). Results: No baseline differences were found. At 30 min post resuscitation pulmonary capillary wedge pressure and LVEDP were significantly higher (16±3 vs. 7±1 and 20±2 vs. 11±1 mmHg) while LV isovolumic relaxation (‘Tau’) was significantly longer (34±2 vs. 20±2 ms) in the IABP treated versus the dobutamine treated animals. Likewise, at 6 h post resuscitation LV ejection fraction was significantly less (21±6 vs. 39±4%), and LVEDP significantly higher (18 vs. 10 mmHg) in the IABP group. Heart rate was not different between the groups at any time post resuscitation. Conclusion: Dobutamine was superior to IABP for treatment of post resuscitation left ventricular systolic and diastolic dysfunction. The hypothesized advantage of IABP for treatment of post resuscitation myocardial stunning without excessively raising the heart rate like dobutamine was not realized.

The Effect of Early IABP and Reperfusion therapy in Patient of Post MI Cardiogenic shock

Background: We sought to examine the use and outcomes of early intraaortic balloon counterpulsation(IABP) combined with early reperfusion therapy in patients presenting cardiogenic shock complicated acute myocardial infarction. The usc of IABP in patients with cardiogenic shock is widely accepted. However there is not ample information on the use of this technique in patients with cardiogenic shock who arc treated with reperfusion therapy in Korea. Materials and Methods: Twenty-eight patients presented with cardiogenic shock were classified into two groups: the early IABP group (insertion within 12 hours after AMI onset time) and the late IABP group (insertion after 12 hours). We compared In-hospital mortality between the two groups (early IABP group vs late IABP group). Results: Two groups showed no significant difference in clinical feature and coronary angiographic results. Among total 28 patients, 7 patients were treated with thrombolytic therapy and 21 patients with PTCA. Insertion site bleeding, fever, thrombocytopenia were reported as some of the complications of IABP insertion. In-hospital mortalities in the early IABP group and late IABP group were 4 patients(25%) and 8 patients(66%), respectively(p

Cyclooxygenase Activity in the Thoracoabdominal Aorta After 24 Hours of Intraaortic Balloon Counterpulsation: An Assessment of the Effects of Localized Mechanical Trauma

Using a canine model, the authors evaluated the effects of twenty-four hours of intraaortic balloon counterpulsation (IABCP) on the morphology of the thoracoabdominal aorta and its spontaneous and arachidonate stimulated pro duction of prostacyclin (PGI2). The treated group was counter-pulsed at a 1:1 ratio with a 40 cc balloon. The control group had the balloon inserted and left deflated across the thoracoabdominal aorta. There were no differences between the IABCP or sham groups in prostanoid production either in the thoracic or abdominal aorta. Baseline PGI2 production in the control versus treated group of thoracic aortas was 1880 ± 1140 pg/cm2/ min vs 1992 ± 1125. The stimulated response in the control group, 9180 ± 1198, was statistically different from baseline (P < .001). The stimulated in crease in the IABCP group, 6269 ± 5240, relative to baseline was also signifi cant (P < .01). There were no significant differences, either between or within groups in the abdominal aortas. Poststimulation values (30 min) were signifi cantly below baseline in each group in each section of the aorta (P < .05). Light microscopy showed a statistically significant difference in endothelial preserva tion between the control and the balloon group, 66 ± 25% vs 19 ± 17% (P < 0.05) . The authors conclude that IABCP results in severe endothelial destruction but that spontaneous and stimulated PGI2 production is unimpaired. It remains to be determined whether the aorta may sustain long-term damage due to the repair process after IABCP.