Intra-aortic Balloon Counterpulsation In Patients Research Articles

A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines?

Aims Intra-aortic balloon counterpulsation (IABP) in ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock is strongly recommended (class IB) in the current guidelines. We performed meta-analyses to evaluate the evidence for IABP in STEMI with and without cardiogenic shock. Methods and results Medical literature databases were scrutinized to identify randomized trials comparing IABP with no IABP in STEMI. In absence of randomized trials, cohort studies of IABP in STEMI with cardiogenic shock were identified. Two separate meta-analyses were performed respectively. The first meta-analysis included seven randomized trials (n = 1009) of STEMI. IABP showed neither a 30-day survival benefit nor improved left ventricular ejection fraction, while being associated with significantly higher stroke and bleeding rates. The second meta-analysis included nine cohorts of STEMI patients with cardiogenic shock (n = 10529). In patients treated with thrombolysis, IABP was associated with an 18% [95% confidence interval (CI), 16-20%; P < 0.0001] decrease in 30 day mortality, albeit with significantly higher revascularization rates compared to patients without support. Contrariwise, in patients treated with primary percutaneous coronary intervention, IABP was associated with a 6% (95% CI, 3-10%; P < 0.0008) increase in 30 day mortality. Conclusion The pooled randomized data do not support IABP in patients with high-risk STEMI. The meta-analysis of cohort studies in the setting of STEMI complicated by cardiogenic shock supported IABP therapy adjunctive to thrombolysis. In contrast, the observational data did not support IABP therapy adjunctive to primary PCI. All available observational data concerning IABP therapy in the setting of cardiogenic shock is importantly hampered by bias and confounding. There is insufficient evidence endorsing the current guideline recommendation for the use of IABP therapy in the setting of STEMI complicated by cardiogenic shock. Our meta-analyses challenge the current guideline recommendations.

The use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: Data from the National Registry of Myocardial Infarction 2

Background Cardiogenic shock complicating acute myocardial infarction (AMI) remains the leading cause of death in patients hospitalized with AMI. Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery, it remains unclear as to whether intra-aortic balloon counterpulsation (IABP) provides incremental benefit to reperfusion therapy. The purpose of this study was to determine whether IABP use is associated with lower in-hospital mortality rates in patients with AMI complicated by cardiogenic shock in a large AMI registry. Methods We evaluated patients participating in the National Registry of Myocardial Infarction 2 who had cardiogenic shock at initial examination or in whom cardiogenic shock developed during hospitalization (n = 23,180). Results The mean age of patients in the study was 72 years, 54% were men, and the majority were white. The overall mortality rate in all patients who had cardiogenic shock or in whom cardiogenic shock developed was 70%. IABP was used in 7268 (31%) patients. IABP use was associated with a significant reduction in mortality rates in patients who received thrombolytic therapy (67% vs 49%) but was not associated with any benefit in patients treated with primary angioplasty (45% vs 47%). In a multivariate model, the use of IABP in conjunction with thrombolytic therapy decreased the odds of death by 18% (odds ratio, 0.82; 95% confidence interval, 0.72 to 0.93). Conclusions Patients with AMI complicated by cardiogenic shock may have substantial benefit from IABP when used in combination with thrombolytic therapy. (Am Heart J 2001;141:933-9.)

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

Enhanced external counterpulsation in the management of patients with cardiovascular disease.

Studies over the past several decades support the hypothesis that enhanced external counterpulsation (EECP) can provide long-term benefits in patients with angina secondary to chronic coronary disease. Numerous non-sham controlled trials have recently been substantiated by a multicenter, randomized trial. Although the mechanism by which this mechanical treatment effects an alteration in cellular processes within the myocardium remains unclear, recent scientific investigations suggest that shear stress induced by chronic exposure to EECP might result in the release of a variety of growth factors and the subsequent stimulation of angiogenesis in the coronary beds. Ongoing clinical trials in patients with significant left ventricular dysfunction, an international registry, and additional clinical trials may help to elucidate further the role of this novel and unique therapy in our clinical armamentarium.

Intravenous thyroid hormone supplementation in heart failure with cardiogenic shock

Background: Thyroid hormone level abnormalities commonly exist in severe heart failure and may be of prognostic value. The therapeutic potential of using thyroid hormone for cardiogenic shock resulting from progressive heart failure has not been previously delineated. We sought to evaluate the role of an intravenous infusion of thyroxine as an adjunct to conventional inotropic agents and intra-aortic balloon counterpulsation in patients with severe heart failure with cardiogenic shock. Methods and Results: We studied 10 consecutive patients with severe systolic heart failure that progressed to a cardiogenic shock state unresponsive to conventional pharmacological inotropic measures. Intravenous thyroxine (20 μg/h) was used as an adjunctive salvage measure after the failure of conventional pharmacological and mechanical support by intraaortic balloon pump. The invasive hemodynamic profile (right atrial pressure, pulmonary capillary wedge pressure, cardiac index, mean arterial pressure), overall clinical status, core temperature, renal function, and tachyarrhythmias were compared before and sequentially at 6, 24, and 36 hours after the initiation of thyroxine administration. Long-term outcome was also defined. All patients had statistically significant improvements in cardiac index, pulmonary capillary wedge pressure, and mean arterial pressure at 24 and 36 hours post-initiation of thyroxine. No sustained tachyarrhythmias were seen during the thyroxine infusion. In 9 of 10 patients who underwent left ventricular assist device placement and/or heart transplantation, the use of thyroxine served as an effective adjunctive measure to allow transitioning to definitive surgical therapy. The 6-month and 1-year cohort survival rates, achieved by the transition to surgical therapy, were 90% and 80%, respectively. Conclusion: The beneficial hemodynamic properties of intravenous thyroid hormone can be effectively used in otherwise terminal situations of cardiogenic shock, and in such situations, the use of thyroid hormone can serve as a pharmacological adjunct to a definite surgical intervention. Further studies in larger numbers of patients might be warranted to confirm these findings.

Intra-aortic balloon counterpulsation in patients with severe cardiac dysfunction undergoing abdominal operations.

To assess the effectiveness of intra-aortic balloon counterpulsation (IABC) as adjunctive treatment in patients undergoing abdominal operations. Retrospective review of patient medical records to determine the incidence of mortality following abdominal surgery and the incidence of complications from IABC. University-based, tertiary care hospital. Sixty-eight patients who underwent an abdominal operation and IABC during the same hospitalization were divided into the following groups: Group 1, IABC initiated prior to operation to enhance perioperative cardiac function; group 2, IABC used to treat cardiogenic shock in a patient who subsequently required an operation while undergoing IABC; and group 3, IABC device inserted and removed for treatment of cardiogenic shock in a patient who subsequently required an operation within 30 days of removal of the device. The incidence of mortality in IABC-supported patients and IABC-related complications. In group 1, excluding 3 patients who died following emergency operation, 26 patients underwent nonemergency procedures and had a 12% mortality rate. In group 2, 5 of 6 patients who underwent emergency operations died, whereas 3 of 4 patients who required only urgent operations survived. In group 3, 18 (62%) of 29 patients who underwent urgent or emergent operations died postoperatively. Thirteen patients experienced complications related to IABC; there were no deaths and no limbs were lost to ischemia. This is the largest reported series looking at the utility of IABC as adjunctive treatment for patients undergoing abdominal operations. The outcome for those patients requiring emergency operations remains poor, but it is likely that more liberal use of IABC in patients with severe cardiac dysfunction who require nonemergency operations may improve patient outcome.

Effective arterial elastance and the hemodynamic effects of intraaortic balloon counterpulsation in patients with coronary heart disease

Objectives The goal of the present study was to analyze the effects of different intraaortic balloon counterpulsation (IABC) inflation volumes on effective arterial elastance (Ea) in patients with complicated coronary heart disease and to determine whether Ea can predict the hemodynamic response to IABC. Background Ea (the central aortic end-systolic pressure to stroke volume ratio) incorporates the principal elements of input arterial impedance and has been proved useful to evaluate the effects of afterload reduction in patients with left ventricular (LV) failure. However, although the hemodynamic action of IABC can be considered as a typical example of "pure" afterload reduction, it has never been assessed in terms of changes in Ea. Methods After clinical stabilization, 18 patients treated with IABC for complicated acute myocardial infarction or unstable angina were enrolled in the study. Systemic hemodynamics were measured by use of right cardiac thermodilution catheters with IABC off (control) and IABC on at balloon inflation volumes of 20 and 40 ml, in randomized sequence. Aortic pressure was recorded through the central lumen of the IABC catheter to calculate Ea as the ratio of aortic dicrotic pressure to stroke volume. Results A higher control Ea was associated with a lower control LV stroke work and a larger IABC-related hemodynamic improvement (that was maximal with the 40 ml inflation volume). The increase in LV stroke work was closely related to the decrease in Ea. Accordingly, hemodynamic benefits from IABC were less evident in patients with lower control Ea. In conclusion, effects of IABC were related to both balloon inflation volume and control hemodynamics, reflecting the afterload dependence of a depressed LV function. (Am Heart J 1998;135:855-61.)

Use of Intra-aortic Balloon Counterpulsation in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

Use of Intra-aortic Balloon Counterpulsation in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

Use of intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock

Use of intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock

Economic Implications of the Prophylactic Use of Intraaortic Balloon Counterpulsation in the Setting of Acute Myocardial Infarction

Intraaortic balloon counterpulsation (IABP) has been shown to improve coronary artery patency and reduce the rates of recurrent myocardial ischemia and its sequelae in selected patients when used within 24 hours of acute myocardial infarction. The economic implications of prophylactic IABP use are unknown. We obtained hospital bills for 102 patients enrolled in the Randomized IABP Trial (56%) and converted charges to costs using each hospital′s Medicare cost report. In-hospital costs for patients who had 48 hours of IABP were compared with those of patients who did not. The costs of angiographic and clinical complications were determined. Small differences in clinical and angiographic characteristics existed between patients in the economic substudy and the overall population, but overall angiographic and clinical outcomes were comparable. Costs for patients who had IABP versus control patients were similar: mean $22,357 ± $14,369 versus $19,211 ± $8,414, median (25th and 75th percentiles) $17,903 ($15,787, $22,147) versus $17,913 ($15,144, $21,433), p = 0.45. Hospital costs were higher with the development of recurrent ischemia: mean $23,125 ± $7,690 versus $20,416 ± $12,449, median $21,069 ($17,896, $26,885) versus $17,492 ($14,892, $20,998) p = 0.02. Patients who had an adverse clinical event (death, stroke, reinfarction, and emergency revascularization) also had higher hospital costs: mean $25,598 ± $10,024 versus $19,790 ± $12,045, median $21,877 ($18,380, $28,049) versus $17,364 ($14,773, $20,779), p = 0.002. The prophylactic use of IABP in patients at high risk of infarct artery reocclusion within 24 hours of acute myocardial infarction provides sustained clinical benefit without substantially increasing hospital costs.We compared in-hospital costs for 96 patients randomized to receive 48 hours of prophylactic intraaortic balloon counterpulsation (IABP) within 24 hours of acute myocardial infarction with those of 86 patients randomized to standard treatment. Costs were similar between groups—median $17,903 versus $17,913, p = 0.45—and ischemic complications were significantly reduced with this approach.

Effects of intraaortic balloon pumping on coronary and carotid flow during percutaneous cardiopulmonary support

Previous studies have suggested an improved clinical outcome when percutaneous cardiopulmonary support is combined with intraaortic balloon counterpulsation in patients with cardiogenic shock. We evaluated the effect of combined intraaortic balloon counterpulsation and percutaneous cardiopulmonary support therapy on coronary and cerebral blood flow by Doppler measurements in the coronary and the carotid arteries in a patient with cardiac arrest. During pacemaker stimulation, intraaortic balloon counterpulsation in addition to percutaneous cardiopulmonary support markedly improved coronary and carotid blood flow. Possible mechanisms are discussed.

Safety of intraaortic balloon counterpulsation in patients with acute myocardial infarction receiving streptokinase intravenously

Intraaortic balloon counterpulsation (IABC) was initially described in 1968, 1 and has become widely used in the treatment of patients with acute myocardial infarction (AMI), 2 cardiogenic shock 1,3 and in those undergoing cardiac surgery 3 or percutaneous transluminal coronary angioplasty.4 The complication rate in patients treated with IABC has ranged between 25 and 36%. 3,5,6 Recently, the use of thrombolytic agents has become widely accepted in the treatment of patients with AMI. 7,8 A significant complication of intravenous thrombolytic therapy is bleeding, especially involving sites of access for cardiac catheterization. 9 When catheterization is performed early after intravenous thrombolytic treatment, the incidence of local bleeding ranges from 18 to 43%. 9 The risk of IABC soon after intravenous thrombolytic therapy has not been previously examined.

Cardiac Pathology: An Integrated Text and Colour Atlas

In the past two decades, rapid advances have occurred in our understanding of the mechanism of normal cardiac contraction and of the effects of aging and disease on cardiac function. Much of this increase in knowledge has been the result of dramatic improvements in diagnostic imaging techniques, such as two-dimensional echocardiography and a variety of nuclear imaging techniques. More aggressive approaches to patients with common diseases—such as thrombolytic interventions in coronary thrombosis and intra-aortic balloon counterpulsation in patients with unstable angina or with complications from infarction—in conjunction with advances in surgical treatment for such patients have resulted in a need for greater appreciation of cardiac pathology. Thus, although a detailed understanding of cardiac morphology has always been essential to pediatric cardiologists and cardiothoracic surgeons, internists, cardiologists, and radiologists now require an appreciation of the morphological manifestations of cardiovascular disorders. This handsome atlas of cardiac pathology is an exciting edition. The

Regional and global left ventricular function during intra-aortic balloon counterpulsation in patients with acute myocardial infarction shock

We evaluated the improvement in hemodynamic and left ventricular (LV) function in 15 patients with acute myocardial infarction and cardiogenic shock, who were treated with intraaortic balloon counterpulsation (IABP). They were studied by flow-directed right heart catheterization and nuclear angiography. IABP decreased LV end-diastolic volume from 134 to 114 ml and LV end-systolic volume from 100 to 72 ml. LV stroke volume increased from 34 to 42 ml and cardiac output from 3.0 to 3.6 L/min. Global LV ejection fraction increased from 27.6% to 36.1%, and this was due to improvement in regional ejection fraction in ischemic areas. Pulmonary capillary wedge pressure and pulmonary blood volume decreased. Right ventricular ejection fraction also increased significantly. IABP improved LV function in acute myocardial infarction.

Augmentation of regional coronary blood flow by intra-aortic balloon counterpulsation in patients with unstable angina.

Intra-aortic balloon counterpulsation is capable of reducing afterload in patients with unstable angina. Whether it is also capable of augmenting coronary blood flow to poststenotic myocardium is controversial. We studied seven patients receiving maximal drug therapy and requiring balloon pumping for unstable angina as balloon volume and assist ratio were altered. All patients had greater than 90% stenosis of the proximal left anterior descending coronary artery. With maximal augmentation (40 cc balloon volume, 1:1 assist ratio) great cardiac vein flow, representing the efflux from the left anterior descending coronary artery bed, rose from a baseline of 52 +/- 20 to 67 +/- 25 ml/min (mean +/- SD, p = .004) and mean aortic diastolic pressure increased from 77 +/- 13 to 99 +/- 33 mm Hg (p = .004). Increased great cardiac vein flow correlated with increased mean aortic diastolic pressure across changes in balloon volumes (off, 20 cc, 30 cc, and 40 cc) and changes in assist ratio (off, 1:4, 1:2, and 1:1) (p = .02). However, the intermediate balloon volumes produced great cardiac vein flows at an intermediate level between full assist and no assist (p less than .05), whereas the intermediate assist ratios did not augment flow. Thus balloon pumping increased flow to a bed fed by collateral vessels or critical stenoses; this increased flow correlated with increased aortic diastolic pressure, indicating probable loss of autoregulatory ability.

Unstable angina: The case for operation

From July 1975 through September 1977, surgical revascularization was performed in 95 consecutive patients with unstable angina, 53 at high risk (defined as in-hospital pain at rest with reversible ischemic electrocardiographic changes) and 42 at low risk (defined as pain at rest remitting upon hospitalization). Historical, electrocardiographic and cardiac catheterization data were similar in both groups; however, patients at high risk required large doses of propranolol, and one patient needed additional intraaortic counterpulsation for preoperative stabilization of ischemia. Proximal left anterior descending (79 patients) and left main (15 patients) coronary artery disease with abnormal ventricular function characterized both groups of patients with unstable angina. Revascularization (2.5 grafts/patient) was performed with hypothermia and intermittent ischemic arrest. Complications included one death and three perioperative infarctions. No patient needed inotropic support. No late deaths occurred in a follow-up period of up to 30 months. The data indicate that (1) “prophylactic” preoperative intraaortic balloon counterpulsation in patients with unstable angina, although advocated by some surgeons, is unnecessary; (2) the very small incidence of complications when unstable angina—particularly high risk unstable angina—is managed as outlined strongly suggests that surgical revascularization is definitive therapy; and (3) the therapeutic implications of large scale controlled studies of medical versus surgical therapy for unstable angina, which include results achieved 3 or 4 years ago and describe significantly higher rates of mortality and infarction than those reported here and by others, may not be pertinent to therapeutic decisions made today.

The hemodynamic response to intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction

Sixteen patients with cardiogenic shock complicating acute myocardial infarction underwent serial hemodynamic studies during intra-aortic balloon counterpulsation (IABC) at an assist frequency of 1:1. Significant increase was noted during the first 12 hours of IABC in the systemic artery peak diastolic pressure (assisted), cardiac index, stroke index, and stroke work index. During the second 12 hours further significant improvement was noted in the latter three parameters and, in addition, the systemic artery systolic pressure increased significantly. The pulmonary wedge pressure fell as did the total systemic resistance (TSR) during the first 24 hours of IABC. Patients found to be balloon independent after reduction in balloon assist frequency demonstrated significantly greater increase in systemic artery peak diastolic pressure during the first 12 hours of IABC than did those patients found to be balloon dependent. Likewise, the improvement noted in CI, SI, and SWI during the second 12 hours of IABC was of greater magnitude in balloon-independent than in balloon-dependent patients. The data suggest late hemodynamic deterioration after 48 hours of IABC. It is concluded that IABC is effective in improving the deranged hemodynamics of cardiogenic shock. Maximum response is noted between 24 and 48 hours. It is suggested that patients who are balloon independent may be distinguished from those who are balloon dependent by the hemodynamic response within the first 24 hours of IABC.

Improved survival afforded by intra-aortic balloon counterpulsation in patients with poor left ventricular function undergoing aorto-coronary bypass

Improved survival afforded by intra-aortic balloon counterpulsation in patients with poor left ventricular function undergoing aorto-coronary bypass

Mechanical circulatory assistance with intra-aortic balloon counterpulsation for major abdominal surgery.

Intra-aortic balloon counterpulsation (IABC) provides effective mechanical circulatory assistance (MCA) in many patients with cardiac disease characterized by low cardiac output and/or myocardial ischemia. The intra-aortic balloon pump (IABP) has been used almost exclusively in the care of patients with cardiac disease as their primary medical disorder. This report presents use of the IABP in three cases where cardiac disease was present, but abdominal pathology necessitating urgent surgical intervention was the primary medical concern. Experience with these three cases suggest that operative and early postoperative use of IABC in patients with documented heart disease undergoing major non-cardiac surgical procedures may reduce the high incidence of cardiac complications.