Milestone research on IABP therapy, dating from 1983 to the present day, has been captured in this concise listing of abstracts. The researchers address major issues facing IABP professionals.
Periodic review of this list is recommended to increase awareness of proper and practical use of IABP therapy. These abstracts are updated annually for the convenience of IABP clinicians, worldwide.
Complete articles can be obtained through on-line medical reference services or by contacting MAQUET Cardiac Assist.
IABP delivers comparable hemodynamic support to the Impella 2.5.
INTRODUCTION: The objective of this study was to determine if Impella 2.5 provides superior hemodynamic support compared with the IABP in cardiogenic shock patients.
METHOD: A prospective, randomized study on 26 patients with cardiogenic shock.
Impella will not demonstrate a significant difference in major adverse events in very high-risk patients when compared to IABP.
Abstract - E P Tsagalou, et al. CHF 2009;15:35-40
Intractable heart failure (HF) remains a leading fatal complication of acute myocardial infarction (AMI). Intra-aortic balloon pump (IABP) counterpulsation assists the failing left ventricle and accelerates the functional recovery of stunned myocardium. Despite its remarkable performance, the beneficial effects of the IABP in the setting of acute HF or cardiogenic shock complicating AMI have not been confirmed in a randomized clinical trial. Instead, large amounts of information have been collected in observational studies or in retrospective analyses of randomized trials of reperfusion strategies in patients with AMI. The strategy of "stabilize with IABP, treat with reperfusion, and transfer for complete revascularization" has, thus far, yielded the best outcomes, and every effort should be made to implement this strategy in all patients presenting with AMI and severe HF.
Abstract - D Burkhoff, et al. AHJ 2006;152:469.e1-469.e8
BACKGROUND & OBJECTOVES: Despite major advances in the treatment of heart failure, cardiogenic shock (CGS) remains associated with substantial mortality. Recent data suggest that the TandemHeart percutaneous ventricular assist device (pVAD) may be useful in the management of CGS. The aim of this prospective randomized study was to test the hypothesis that the TandemHeart (pVAD) provides superior hemodynamic support compared with intraaortic balloon pumping (IABP).
METHODS: Forty-two patients from 12 centers presenting within 24 hours of developing CGS were included in the study and treated in an initial roll-in phase (n = 9) or randomized to treatment with IABP (n = 14) or TandemHeart pVAD (n = 19). Thirty patients (71%) had persistent CGS despite having an IABP in place at the time of study enrollment.
RESULTS: Cardiogenic shock was due to myocardial infarction in 70% of the patients and decompensated heart failure in most of the remaining patients. The mean duration of support was 2.5 days. Compared with IABP, the TandemHeart pVAD achieved significantly greater increases in cardiac index and mean arterial blood pressure and significantly greater decreases in pulmonary capillary wedge pressure. Overall 30-day survival and severe adverse events were not significantly different between the 2 groups.
CONCLUSION: In patients presenting within 24 hours of the development of CGS, TandemHeart significantly improves hemodynamic parameters, even in patients failing IABP. Larger-scale studies are required to assess the influence of improved hemodynamics on survival.
Abstract - M Seyfarth, et al. JACC 2008;52:1584-8
OBJECTIVES: The aim of this study was to test whether the left ventricular assist device (LVAD) Impella LP2.5 (Abiomed Europe GmbH, Aachen, Germany) provides superior hemodynamic support compared with the intra-aortic balloon pump (IABP).
BACKGROUND: Cardiogenic shock caused by left ventricular failure is associated with high mortality in patients with acute myocardial infarction (AMI). An LVAD may help to bridge patients to recovery from left ventricular failure.
METHODS: In a prospective, randomized study, 26 patients with cardiogenic shock were studied. The primary end point was the change of the cardiac index (CI) from baseline. Secondary end points included lactic acidosis, hemolysis, and mortality after 30 days.
RESULTS: Baseline cardiac index (CI) was 1.7 l/min/m2 for both groups. At 4 hours CI was higher with IABP (2.23 l/min) vs. IABP (2.25 l/min). Reversal of serum lactate levels were comparable for both groups. Hemolysis, as measured by free hemoglobin, was significantly higher in Impella patients during the first 24 hours. The Impella patients also required more packed red blood cells and fresh-frozen plasma, while one patient suffered from acute limb ischemia requiring surgery.Overall 30 day mortality was 46% in both groups.
Abstract - J M. Cheng, et al. EHJ doi:10.1093/eurheart/ehp292
OBJECTIVES: Studies have compared safety and efficacy of percutaneous left ventricular assist devices (LVADs) with intra-aortic balloon pump (IABP) counterpulsation in patients with cardiogenic shock. We performed a meta-analysis of controlled trials to evaluate potential benefits of percutaneous LVAD on haemodynamics and 30-day survival.
METHODS & RESULTS: Two independent investigators searched Medline, Embase, and Cochrane Central Register of Controlled Trials for all controlled trials using percutaneous LVAD in patients with cardiogenic shock, where after data were extracted using standardized forms. Weighted mean differences (MDs) were calculated for cardiac index (CI), mean arterial pressure (MAP), and pulmonary capillary wedge pressure (PCWP). Relative risks (RRs) were calculated for 30-day mortality, leg ischaemia, bleeding, and sepsis. In main analysis, trials were combined using inverse-variance random effects approach. Two trials evaluated the TandemHeart and a recent trial used the Impella device. After device implantation, percutaneous LVAD patients had higher CI (MD 0.35 L/min/m2, 95% CI 0.09Ğ0.61), higher MAP (MD 12.8 mmHg, 95% CI 3.6Ğ22.0), and lower PCWP (MD *5.3 mm Hg, 95% CI *9.4 to *1.2) compared with IABP patients. Similar 30-day mortality (RR 1.06, 95% CI 0.68Ğ1.66) was observed using percutaneous LVAD compared with IABP. No significant difference was observed in incidence of leg ischaemia (RR 2.59, 95% CI 0.75Ğ8.97) in percutaneous LVAD patients compared with IABP patients. Bleeding (RR 2.35, 95% CI 1.40Ğ3.93) was significantly more observed in TandemHeart patients compared with patients treated with IABP.
CONCLUSION: Although percutaneous LVAD provides superior haemodynamic support in patients with cardiogenic shock compared with IABP, the use of these more powerful devices did not improve early survival. These results do not yet support percutaneous LVAD as first-choice approach in the mechanical management of cardiogenic shock.
Abstract - H Thiele, et al. EHJ 2007;28:2057-2063
Cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction (AMI). In addition to percutaneous coronary intervention, inotropes, and fluids, intraaortic balloon pumping (IABP) is most widely used for initial haemodynamic stabilization. However, the main limitation of IABP is the lack of active circulatory support and the requirement of a certain level of left ventricular (LV) function. In many patients with severe depression of LV function, haemodynamic support and LV unloading derived from IABP is insufficient to reverse CS. The use of percutaneous LV assist devices (LVAD) with active circulatory support might be beneficial in CS patients not responding to standard treatment including IABP support. This review reports the current experience of percutaneous LVAD in CS complicating AMI.
Ann Thorac Surg 2010;89:953-5
RESULTS: Patient was discharged on post-procedural day 5 and at her 8 month follow-up was found to be symptom free in NYHA functional class I.
DISCUSSION: Percutaneous AVI has become a valid alternative to conventional surgery in selected high-risk patients. However, major complications are still a cause for concern.
Coronary blood flow restoration was effective and life saving. This procedure could not have been successfully performed without hemodynamic support obtained with intra-aortic balloon pump.
Am J Card 2010;105:967-971
INTRODUCTION: Comparison of Hospital Mortality With Intra-Aortic Balloon Counterpulsation Insertion Before Versus After Primary Percutaneous Coronary Intervention for Cardiogenic Shock Complicating Acute Myocardial Infarction
RESULTS: Multivariate analysis identified renal failure and insertion of the IABP after PCI as the only independent predictors of in-hospital mortality.
DISCUSSION: The principle finding of the present analysis was that LV unloading using IABP during primary PCI resulted in a significant reduction in in-hospital mortality.
Mechanical unloading of the ventricle using IABP during ischemia and reperfusion probably results in significant myocardial salvage compared to reperfusion alone. Possible mechanisms include a reduction in myocardial oxygen demand, an increase in coronary artery blood flow and reduced microvascular obstruction, leading to a reduction in infarct expansion after reperfusion.
Barnett MG; Swartz MT; Peterson GJ; Naunheim KS; Pennington DG; Vaca KJ; Fiore AC; McBride LR; Peigh P; Willman VL; et al, Vascular complications from intraaortic balloons: risk analysis. J Vasc Surg, 1994 Jan, 19:1, 81-7; discussion 87-9
PURPOSE: The purpose of this study was to assess the incidence of and predictors for vascular complications in patients who required perioperative intraaortic balloon pump (IABP) support.
METHODS: Data from 580 patients collected with a retrospective review were statistically analyzed with 25 perioperative parameters, and significant variables were evaluated with multivariate analysis. These data were also statistically compared with data from a 1983 study from our institution.
RESULTS: Vascular complications occurred in 72 patients (12.4%). The three aortic perforations were fatal. Ipsilateral leg ischemia occurred in 69 patients. Of these, ischemia was resolved in 82% of patients by IABP removal (21), thrombectomy (21), vascular repair (13), fasciotomy (2), or without intervention (2). Six patients died with the intraaortic balloon in place. Four patients required amputation for ischemia, but all survived.
CONCLUSIONS: Vascular complications were not predictive of operative death (p = 0.26). Risk analyses with 25 perioperative parameters revealed that history of peripheral vascular disease, female sex, history of smoking, and postoperative insertion were independent predictors of vascular complications. However, most risk for vascular complications cannot be explained by these factors because of a low R2 value. Compared with the results of our 1983 study, the incidence of IABP-related complications has not changed, but the severity of complications has decreased significantly, and IABP-induced death has decreased significantly.
Christenson JT; Badel P; Simonet F; Schmuziger M, Preoperative intraaortic balloon pump enhances cardiac performance and improves the outcome of redo CABG. Ann Thorac Surg, 1997 Nov, 64:5, 1237-44
BACKGROUND: Reoperative coronary artery bypass grafting (redo CABG) is associated with an increased operative risk compared with primary CABG. Because the hospital mortality in redo CABG is known to be influenced by poor left ventricular function (left ventricular ejection fraction < or = 0.40), unstable angina, and left main stem stenosis greater than or equal to 70%, a preoperative intraaortic balloon pump (IABP) support could be beneficial to improve the outcome in high-risk redo CABG.
METHODS: Between June 1994 and October 1996, 48 high-risk patients underwent redo CABG and were randomized into the following groups: group 1 (24 patients) who received preoperative IABP treatment on average 2 hours before cardiopulmonary bypass, and group 2 (24 patients) who received no preoperative IABP and served as controls. Mean age was 65 years and 90% (43 patients) were men. Forty-one patients had preoperative left ventricular ejection fraction less than or equal to 0.40 (85%), 38% (18 patients) had left main stem stenosis greater than or equal to 70%, and 54% (26 patients) had unstable angina preoperatively. Preoperative patient characteristics did not differ between the groups.
RESULTS: The time on cardiopulmonary bypass was shorter in group 1, 86 versus 110 minutes (p = 0.006). There were no hospital deaths in group 1, but four deaths occurred in the control group (p = 0.049). Cardiac index rose significantly preoperatively after introduction of the IABP in group 1. Cardiac index was significantly higher postoperatively in group 1 compared with group 2 and remained significantly higher during the first 24 hours after cardiopulmonary bypass. Significantly fewer patients in the IABP group had postoperative low cardiac output (4 versus 13 patients). Nine patients in group 2 required IABP support postoperatively for 4.1 +/- 1.7 days. Only 2 patients in group 1 needed IABP postoperatively, and their IABPs were successfully removed on the first postoperative day. The preoperative IABP-supported patients had a shorter intensive care unit stay, 2.4 +/- 0.8 days compared with group 2, 4.5 +/- 2.2 days (p = 0.007), as well as a shorter hospital stay. The preoperative IABP treatment was found to be cost-effective.
CONCLUSIONS: Preoperative treatment with IABP in high-risk redo CABG patients is an effective modality to prepare these patients to have their myocardial revascularization in an as nonischemic situation as possible, which resulted in a significantly lower hospital mortality, fewer instances of postoperative low cardiac output, and shorter stays in both the intensive care unit and the hospital.
Christenson JT; Simonet F; Badel P; Schmuziger M, Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients. Eur J Cardiothorac Surg, 1997 Jun, 11:6, 1097-103; discussion 1104
OBJECTIVE:The intra-aortic balloon pump (IABP) is an established additional support to pharmacological treatment of the failing heart after myocardial infarction, unstable angina and cardiac surgery. The effect of preoperative IABP in high risk patients was evaluated.
METHODS:Between June 1994 and March 1996 all high risk patients for CABG (two or more of these criteria: Left ventricular ejection fraction (LVEF) < or = 40%, left main stem stenosis > or = 70%, REDO-CABG, unstable angina) were randomized into either of 3 groups: (1) IABP 1 day prior to surgery, (2) IABP 1-2 h prior to CPB and (3) no preoperative IABP, controls. Exclusion criteria: cardiogenic shock preoperatively. Fifty-two patients have entered the study-group 1 (13 patients), group 2 (19 patients) and group 3 (20 patients). Preoperative patient characteristics and operative data revealed no group differences. There were 56% REDO's, unstable angina 59%, LVEF < or = 40%, 87% (34.0 +/- 11.6%) and left main stem stenosis in 35%.
RESULTS:The CPB-time was shorter in groups 1 and 2 88.7 +/- 20.3 min than in group 3 105.5 +/- 26.8 min, P < 0.001, while ischemia time did not differ. Hospital mortality was higher in group 3, 25% vs. 6% (groups 1 and 2). Postoperative low cardiac output was seen in 12 patients (60%) in group 3 vs. 6 patients (19%) in groups 1 and 2, P < 0.05. Cardiac index increased significantly prior to CPB in groups 1 and 2. After CPB cardiac index was significantly higher in groups 1 and 2 compared to Group 3 and continued to increase. The IABP was removed after 3.1 +/- 1.0 days in group 3 vs. 1.3 +/- 0.6 days in groups 1 and 2, P < 0.001. In group 3, 11 patients required IABP postoperatively compared to only 4 patients in groups 1 and 2. ICU stay was shorter in groups 1 and 2--2.3 +/- 0.9 days vs. 3.5 +/- 1.1 days for group 3, P = 0.004. All patients received dopamin postoperatively, however in a lower dose in groups 1 and 2, 4.5 vs. 13.5 microg/kg/min. Dobutamine was added in 23% of the patients (group 1), 32% (group 2) and 95% (group 3). Adrenalin/amrinonum was required in 40% of the patients in group 3, 5% in group 2 and none in group 1. Group 1 patients had a better improvement of cardiac performance than group 2, while other parameters did not differ. Three months follow up of hospital survivors showed no group differences.
CONCLUSIONS:The use of preoperative IABP in high risk patients lowers hospital mortality and shortens the stay in ICU, due to improved cardiac performance, compared to a controls. The procedure was cost-beneficial. One day preoperative IABP treatment improves cardiac performance more than 1-2 h preoperative IABP treatment, but does not significantly affect the outcome in terms of hospital mortality or postoperative morbidity.
Dietl CA; Berkheimer MD; Woods EL; Gilbert CL; Pharr WF; Benoit CH, Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Ann Thorac Surg, 1996 Aug, 62:2, 401-8; discussion 408-9
BACKGROUND:The purposes of this study are to determine whether patients with severe left ventricular dysfunction benefit from prophylactic insertion of an intraaortic balloon pump and to evaluate its cost-effectiveness.
METHODS:Between January 1991 and December 1995, 163 consecutive patients with a left ventricular ejection fraction of 0.25 or less underwent isolated coronary artery bypass grafting. An intraaortic balloon pump was inserted before operation in 37 patients (group A). The remaining 126 patients underwent operation without preoperative insertion of the device (group B). Preoperatively, 91.9% (34/37) of group A patients and 54.8% (69/126) of group B patients were in New York Heart Association functional class III or IV (p < 0.001).
RESULTS:The 30-day mortality rate was 2.7% (1/37) and 11.9% (15/126) for groups A and B, respectively (p < 0.005). All deaths occurred in patients in functional class III or IV. In group B, 28 patients (22.2%) required an intraaortic balloon pump after cardiotomy for low cardiac output, 42.9% (12/28) of whom died. Median postoperative hospital stay was 9.9 days and 12.0 days, and mean hospital charges were $50,627 and $54,818 for survivors in groups A and B; respectively (p = not significant).
CONCLUSIONS:Our experience suggests that patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting may benefit from preoperative intraaortic balloon pump insertion, especially patients in functional class III or IV. This approach improved survival significantly, reduced hospital stay, and was more cost-effective.
Eltchaninoff H; Dimas AP; Whitlow PL, Complications associated with percutaneous placement and use of intraaortic balloon counterpulsation. Am J Cardiol, 1993 Feb, 71:4, 328-32
In-hospital and late complications related to percutaneous placement of 240 intraaortic balloon pump catheters in 231 consecutive patients from March 1985 through June 1990 were reviewed. Mean age was 64 +/- 11 years and 34% were women. Average duration of counterpulsation was 44.2 hours. Indications for counterpulsation included complications of myocardial infarction (34.6%), prophylactic placement before high-risk coronary angioplasty (20.0%) or open heart surgery (12.9%), complicated coronary angioplasty (18.3%), end-stage cardiomyopathy (5.4%) and miscellaneous (8.8%). Early major complications occurred in 11 cases (4.6%) and included limb ischemia requiring surgery (n = 9), bleeding requiring arterial repair (n = 1) and septicemia (n = 1). Other complications included hematoma requiring transfusion (n = 7), limb ischemia resolving with balloon catheter removal (n = 12), and superficial wound infection (n = 1). Overall in-hospital complication rate was 13% (31 of 240). Peripheral vascular disease and diabetes were found to be significant predictors of limb ischemia (p = 0.01 and p = 0.02, respectively). Follow-up information was obtained in 97% of patients with a mean duration of 19 months: 2 patients (1.1%) required vascular surgery for femoral false aneurysms and 1 patient experienced new onset of claudication. In conclusion, compared with previous experience, contemporary intraaortic balloon counterpulsation with percutaneous placement of smaller size (8.5Fr to 10.5Fr) catheters is associated with improved complication profile. This will further enhance the current trend for an expanding role of intraaortic balloon counterpulsation in complex interventional procedures.
Ingram JM, Innovations in intra-aortic balloon pump management: Computer modem technology, J Extra-Corporeal Technology 1994;26(3):135-139
The computer modem technology being developed by Datascope Corp. for the purpose of off-site intra-aortic balloon pump (IABP) monitoring was clinically evaluated in 30 patients requiring IABP support. The Datascope System 95 model IABP with built-in modem was used on all patients. Remote communications via a personal computer with modem were conducted under both routine and emergency settings. The Datascope PC IABP software was evaluated for its user compatibility, efficiency, diagnostic capability and overall usefulness as a clinical tool. During the eight month evaluation period, 87 remote communications were conducted for both routine and emergency IABP evaluation checks. Adjustments were recommended on 22 occasions relevant to balloon timing, trigger mode selection and augmentation volume settings. Eight communications were initiated in emergency settings due to a variety of patient conditions. Emergency intervention was successful in diagnosing and resolving critical situations including atrial arrhythmias, pacemaker timing, low cardiac output syndrome, loss of trigger source, catheter malpositioning and poor augmentation. The diagnostic capabilities and efficient means of data collection by the computer software provide the clinician with a valuable tool for routine IABP clinical monitoring, as well as emergency problem resolution.
Kern MJ; Aguirre FV; Tatineni S; Penick D; Serota H; Donohue T; Walter K, Enhanced coronary blood flow velocity during intraaortic balloon counterpulsation in critically ill patients. J Am Coll Cardiol, 1993 Feb, 21:2, 359-68
OBJECTIVE:The aim of this study was to assess coronary blood flow during intraaortic balloon counterpulsation by direct measurement.
BACKGROUND:In a majority of human studies, increased coronary blood flow during intraaortic balloon counterpulsation measured by indirect techniques has not been consistently demonstrated.
METHODS:Hemodynamic variables and coronary blood flow velocity (20-MHz Doppler-tipped catheter) data were measured in 19 patients requiring intraaortic balloon pumping for clinical indications (11 patients had acute myocardial infarction [9 with shock], 6 had unstable angina, 1 had acute mitral regurgitation and 1 was at high risk undergoing angioplasty). Hemodynamic data, mean and phasic diastolic flow velocity and velocity-time integrals (computed from digitized waveforms) were analyzed during periods of 1:1 balloon counterpulsation. RESULTS. Intraaortic balloon pumping decreased systolic pressure (6 +/- 10%, p < 0.001) and increased diastolic pressure (80 +/- 30% from baseline, p < 0.001) without changing RR interval. Peak phasic, mean coronary flow velocity and diastolic flow velocity integral were significantly increased (115 +/- 115%, 67 +/- 61%, 103 +/- 81%, respectively, all p < 0.001) during intraaortic balloon pumping. In addition, although a wide splay of data was evident due to operator set variations in balloon inflation and deflation timing, the greater increases in diastolic flow velocity integral (DFVi) occurred in patients with basal systolic pressure < or = 90 mm Hg (% delta DFVi = 102 - 0.1.[unaugmented systolic pressure], SEE = 21.7 mm Hg, r = 0.30, p < 0.001).
CONCLUSIONS:Intraaortic balloon pumping unequivocally and significantly augments proximal coronary blood flow velocity, nearly doubling the coronary flow velocity integral in most patients. This mechanism may be a significant means of ischemia relief in hypotensive patients.
Kovack PJ; Rasak MA; Bates ER; Ohman EM; Stomel RJ, Thrombolysis plus aortic counterpulsation: improved survival in patients who present to community hospitals with cardiogenic shock. J Am Coll Cardiol, 1997 Jun, 29:7, 1454-8
OBJECTIVE:We sought to explore the potential benefit of combining intraaortic balloon counterpulsation (IABP) with thrombolysis for acute myocardial infarction (MI) complicated by cardiogenic shock.
BACKGROUND:In community hospitals, this condition is usually managed with thrombolysis alone.
METHODS:We reviewed the charts of 335 patients from two community hospitals who presented with acute MI and had cardiogenic shock between 1985 and 1995. RESULTS: Of 46 patients who underwent thrombolysis within 12 h of acute infarction with confirmed cardiogenic shock, 27 underwent IABP and 19 did not. Age, systolic blood pressure with shock, pulmonary artery catheter use, pulmonary capillary wedge pressure and the incidence of diabetes mellitus and anterior MI did not differ between groups. Patients treated with IABP were somewhat more likely to have prior MI and had a significantly greater cardiac index (2.0 vs. 1.5 liters/min per m2, p = 0.04). Although no deaths occurred within 2 h of presentation, patients not treated with IABP tended to die earlier (6.8 +/- 5 vs. 23.8 +/- 19 h, p = 0.13). Patients treated with IABP had a significantly higher rate of community hospital survival (93% vs. 37%, p = 0.0002), and more of them were transferred for revascularization (85% vs. 37%). Of 30 patients transferred for revascularization, 27 underwent angioplasty or bypass surgery; hospital survival was 74%. Patients treated with IABP also had a significantly higher overall hospital and 1-year survival rate (67% vs. 32%, p = 0.019).
CONCLUSIONS:Survival may be enhanced and transfer for revascularization facilitated when community hospitals use both thrombolysis and IABP to treat patients with acute MI complicated by cardiogenic shock.
Nash IS; Lorell BH; Fishman RF; Baim DS; Donahue C; Diver DJ, A new technique for sheathless percutaneous intraaortic balloon catheter insertion. Cathet Cardiovasc Diagn, 1991 May, 23:1, 57-60
Intraaortic balloon counterpulsation is helpful for controlling myocardial ischemia and providing hemodynamic support, but its applicability is limited by lower extremity ischemic complications in a significant percentage of patients. We developed a new sheathless technique for percutaneous intraaortic balloon catheter insertion which reduces the effective catheter diameter. A pilot study using this new technique resulted in a 10% rate of limb ischemia, without compromise of balloon function. We conclude that this technique may be useful in reducing the incidence of limb ischemia associated with intraaortic balloon counterpulsation.
O'Murchu B; Foreman RD; Shaw RD; Brown DL; Peterson KL; Buchbinder M, Role of intraaortic balloon pump counterpulsation in high risk coronary rotational atherectomy, J Am Coll Cardiol 1995;26:1270-5
OBJECTIVE:This study sought to evaluate the role of intraaortic balloon pump counterpulsation in preventing hemodynamic instability and promoting a successful outcome during percutaneous transluminal coronary rotational atherectomy in high risk patients.
BACKGROUND:The application of rotational atherectomy has widened to include patients with complex lesions and left ventricular dysfunction. Although intraaortic balloon pumping has been successfully used to provide hemodynamic support during balloon angioplasty, its role in high risk rotational atherectomy has not yet been defined.
METHODS:In a retrospective review of 159 consecutive high risk patients who underwent rotational atherectomy, 28 had an intraaortic balloon pump placed electively before the procedure (Group 1) whereas 131 did not (Group 2). RESULTS. Group 1 was older and more likely to have multivessel disease and left ventricular dysfunction. Augmented diastolic pressure was maintained >90mmHg in all Group 1 patients, and significant procedure-related hypotension was encountered in nine Group 2 patients, requiring an emergency intraaortic balloon pump in five. Procedural success was achieved in all 28 patients in Group 1 and in 118 in Group 2 (p=0.07). Slow flow occurred in 18% and 17% of Group 1 and 2 patients, respectively. Among patients with slow flow, non-Q wave myocardial infarction occurred only in Group 2 (0% vs. 27%). On multivariate analysis, elective intraaortic balloon pump placement was the only variable to correlate with a successful procedure uncomplicated by hypotension (p<0.05). Hospital stay and vascular complications were similar in both groups.
CONCLUSIONS:Elective placement of an intraaortic balloon pump before coronary rotational atherectomy in selected high risk patients promotes both procedural hemodynamic stability and a successful outcome.
Ohley WJ; Antonelli L; Leschinsky B, Influence of catheter and arterial diameter on flow distal to an intra-aortic balloon insertion site: a theoretic examination and in vitro assessment. ASAIO J, 1998 Nov, 44:6, 786-93
Percutaneous placement of an intra-aortic balloon (IAB) through a femoral artery of a patient is associated with a risk of reduction of blood flow distal to the balloon insertion site. If this reduction is severe, it ultimately causes limb ischemia and necessitates IAB removal. Although clinicians intuitively know that larger catheters cause higher flow restrictions, very few studies have examined this situation quantitatively. The authors theoretically analyzed the insertion site geometry in relationship to the catheter diameter and other factors effecting distal flow. To verify the findings, in vitro flow tests were conducted with various IAB catheters currently available on the market, as well as their respective sheaths and hemostasis plugs. This was done using a blood analog solution in an array of polyvinyl chloride tubing sizes. Diameters of the vessel and catheter have a profound and nonlinear effect on the distal flow. For example, a 12.2 Fr catheter in a 0.187 in. vessel only allows 19.9% of normal flow, whereas a 6.1 Fr catheter in the same size vessel allows a 92.0% flow. As the catheter diameter increases, the physical resistance suddenly grows, which causes a significant drop in distal flow. These results are accurately predicted by a mathematical model that gives flow percentage results to within 15% of those measured experimentally. In general, vessels larger than 5 mm in diameter do not exhibit substantial flow reduction for most IABs with and without sheaths. In smaller vessels, however, this reduction may be significant. Sheathless insertion is extremely effective in improving distal blood flow in such a situation. Hemostasis plugs restrict the distal flow similar to respective sheaths, thus diminishing the benefits of sheathless insertion.
Ohman EM; George BS; White CJ; Kern MJ; Gurbel PA; Freedman RJ; Lundergan C; Hartmann JR; Talley JD; Frey MJ; et al, Use of aortic counterpulsation to improve sustained coronary artery patency during acute myocardial infarction. Results of a randomized trial. The Randomized IABP Study Group. Circulation, 1994 Aug, 90:2, 792-9
BACKGROUND:Aortic counterpulsation has been observed to reduce the rate of reocclusion of the infarct-related artery after patency has been restored during acute myocardial infarction in observational studies. To evaluate the benefit-to-risk ratio of aortic counterpulsation during the early phase of myocardial infarction, a multicenter randomized clinical trial was performed.
METHODS & RESULTS:Patients who had patency restored during acute cardiac catheterization within the first 24 hours of onset of myocardial infarction were randomly assigned to aortic counterpulsation for 48 hours versus standard care. Intravenous heparin was used similarly in both groups and was continued for a median (25th, 75th percentile) of 5 (2,7) days. A total of 182 patients were enrolled; 96 were assigned to aortic counterpulsation and 86 to standard care. Repeat cardiac catheterization was performed at a median of 5 (4,6) days after randomization in 89% of patients assigned to aortic counterpulsation and in 90% of control patients. Patients randomized to aortic counterpulsation had similar rates of severe bleeding complications (2% versus 1%), number of units of blood transfused (mean, 1.3 +/- 2.6 versus 0.9 +/- 1.8 units), and vascular repair or thrombectomy (5% versus 2%) compared with patients treated in a conventional manner. Patients randomized to aortic counterpulsation had significantly less reocclusion of the infarct-related artery during follow-up compared with control patients (8% versus 21%, P < .03). In addition, there was a significantly lower event rate in patients assigned to aortic counterpulsation in terms of a composite clinical end point (death, stroke, reinfarction, need for emergency revascularization with angioplasty or bypass surgery, or recurrent ischemia): 13% versus 24%, P < .04.
CONCLUSIONS:This randomized trial showed that careful use of prophylactic aortic counterpulsation can prevent reocclusion of the infarct-related artery and improve overall clinical outcome in patients undergoing acute cardiac catheterization during myocardial infarction.
Stomel RJ; Rasak M; Bates ER, Treatment strategies for acute myocardial infarction complicated by cardiogenic shock in a community hospital. Chest, 1994 Apr, 105:4, 997-1002
The risk and benefits of three treatment strategies were examined in 64 consecutive patients with acute myocardial infarction and cardiogenic shock. Thirteen patients received thrombolytic therapy (group 1), 29 patients received intra-aortic balloon pump counterpulsation support (group 2), and 22 patients were treated with combined thrombolytic therapy and intra-aortic balloon pump counterpulsation support (group 3). The groups were similar in regard to age, sex, medical history, hemodynamic data, and extent of coronary artery disease. Survival was improved in patients treated with combined thrombolytic therapy and intra-aortic balloon pump counterpulsation support (group 1, 23 percent; group 2, 28 percent; and group 3, 68 percent; p = 0.0049). Seven percent of the patients who remained at the community hospital survived vs 69 percent who were transferred to a tertiary care center (p < 0.001), and 17 percent survived who were treated medically vs 71 percent who received revascularization (p < 0.001). These findings suggest that patients who present to a community hospital in cardiogenic shock can have their conditions stabilized, and they can then be transferred to a tertiary care hospital for revascularization and have the same outcome as patients who initially present to tertiary care hospitals.
Talley JD; Ohman EM; Mark DB; George BS; Leimberger JD; Berdan LG; Davidson Ray L; Rawert M; Lam LC; Phillips HR; Califf RM, Economic implications of the prophylactic use of intraaortic balloon counterpulsation in the setting of acute myocardial infarction. The Randomized IABP Study Group. Intraaortic Balloon Pump. Am J Cardiol 1997 Mar 79;5: 590-4
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.
Wolvek S, The hostile environment of the aging human aorta and the smaller patient--their implications for the intra-aortic balloon. Perfusion, 1994 Mar, 9:2, 87-94
Intra-aortic balloon counterpulsation (IABC) has been a clinical modality since 1968. In the intervening years the patient population has become older, sicker and smaller. Modern balloon design permits the insertion of balloons into this evolving patient population and the balloon is increasingly threatened by the calcific plaque of the aging aorta and by the geometry of the shorter descending thoracic aorta in the smaller patient. Balloon sizing consideration and radiographic verification of balloon position within the aorta will reduce the incidence of balloon damage during IABC.
Jan T. Christenson, MD, PhD, François Simonet, MD, Pierre Badel, MD, and Martin Schmuziger, MD Optimal Timing of Preoperative Intraaortic Balloon Pump Support in High-Risk Coronary Patients Departments of Cardiovascular Surgery and Anesthesiology, Hôpital de la Tour, Meyrin-Geneva, Switzerland
BACKGROUND:Beneficial effects of preoperative intraaortic balloon pump (IABP) treatment, on outcome and cost, in high-risk patients who have coronary artery bypass grafting have been demonstrated. We conducted a prospective, randomized study to determine the optimal timing for preoperative IABP support in a cohort of high-risk patients.
METHODS:Sixty consecutive high-risk patients who had coronary artery bypass grafting (presenting with two or more of the following criteria: left ventricular ejection fraction less than 0.30, unstable angina, reoperation, or left main stenosis greater than 70%) entered the study. Thirty patients did not receive preoperative IABP (controls), 30 patients had preoperative IABP therapy starting 2 hours (T2), 12 hours (T12), or 24 hours (T24), by random assignment, before the operation. Fifty patients had preoperative left ventricular ejection fraction mean, less than 0.30 (less than 0.26 ± 0.08), (n=40) unstable angina, 28% (n=17) left main stenosis, and 32% (n=19) were reoperations.
RESULTS:Cardiopulmonary bypass was shorter in the IABP groups. There was one death in the IABP group and six in the control group. The complication rate for IABP was 8.3% (n=5) without group differences. Cardiac index was significantly higher postoperatively (p < 0.001) in patients with preoperative IABP treatment compared with controls. There were no significant differences between the three IABP subgroups at any time. The incidence of postoperative low cardiac output was significantly lower in the IABP groups (p < 0.001) Iintubation time, length of stay in the intensive care unit and the hospital was shorter in the IABP groups (p=0.211, p < 0.001, and p=0.002, respectively). There were no differences between the IABP subgroups in any of the studied variables.
CONCLUSIONS:The beneficial effect of preoperative IABP in high-risk patients who have coronary artery bypass grafting was confirmed. There were no differences in outcome between the subgroups; therefore, at 2 hours preoperatively, IABP therapy can be started. (Ann Thorac Surg 1999;68:934-9) ©1999 by The Society of Thoracic Surgeons
Jan T. Christenson, M.D., Ph.D. and Martin Schmuziger, M.D. Preoperative Intra-Aortic Balloon Pump Therapy in High-Risk Coronary Patients Impact on Postoperative Inotropic Drug Use Department of Cardiovascular Surgery Hôpital de la Tour Meyrin-Geneva, Switzerland
High-risk coronary patients have an increased likelihood of developing low cardiac output following myocardial revascularization, often requiring postoperative administration of high doses of inotropic and vasoactive agents over a substantial period of time. Preoperative intra-aortic balloon pumping (IABP) therapy reduces hospital mortality and postoperative morbidity, and significantly shortens both the length of stay in the intensive care unit (ICU) and overall duration of hospitalization. The present report focuses on the impact of preoperative IABP therapy on the extent of postoperative drug consumption, using pooled data from two recently published prospective randomized clinical studies of high-risk coronary patients undergoing myocardial revascularization. A total of 62 patients who received preoperative IABP therapy were compared with 50 control patients not receiving such treatment. The total consumption of dopamine, dobutamine and norepinephrine, and the duration of drug administration, were significantly lower in patients receiving preoperative IABP therapy (p<0.000l). The total expense for postoperative inotropic and vasoactive drug therapy was significantly reduced in the IABP group. High-risk coronary patients undergoing myocardial revascularization who receive preoperative IABP IABP therapy demonstrate a significantly reduced need for inotropic and vasoactive drug therapy, in both dosage and required duration of treatment.
Brodie BR; Stuckey TD; Hansen C; Muncy D.; Intra-aortic balloon counterpulsation before primary percutaneous transluminal coronary angioplasty reduces catheterization laboratory events in high-risk patients with acute myocardial infarction. Am J Cardiol 1999 Jul 1;84(1):18-23
The benefit of intra-aortic balloon counterpulsation (IABC) before primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction in high-risk patients has not been well documented. Consecutive patients (n = 1,490) with acute myocardial infarction treated with primary PTCA from 1984 to 1997 were prospectively enrolled in an ongoing registry. Catheterization laboratory events occurred during or after intervention in 88 patients (5.9%), including ventricular fibrillation in 59 patients (4.0%), cardiopulmonary arrest in 46 patients (3.1%), and prolonged hypotension in 33 patients (2.2%). Cardiogenic shock was the strongest predictor of catheterization laboratory events (odds ratio [OR] 2.18, 95% confidence intervals [CI] 1.58 to 3.02) followed by low ejection fraction (<30%) (OR 1.51, 95% CI 1.06 to 2.15) and congestive heart failure (CHF) (OR 1.45, 95% CI 1.01 to 2.07). IABC used before intervention was associated with fewer catheterization laboratory events in patients with cardiogenic shock (n = 1 19) (14.5% vs. 35.1%, p = 0.009), in patients with CHF or low ejection fraction (n = 119) (0% vs. 14.6%, p = 0.10), and in all high-risk patients combined (n = 238) (1 1.5% vs. 21.9%, p = 0.05). IABC was a significant independent predictor of freedom from catheterization laboratory events (OR 0.48, 95% CI 0.29 to 0.79). These data support the use of IABC before primary PTCA for acute myocardial infarction in all patients with cardiogenic shock, and suggest that prophylactic IABC may also be beneficial in patients with CHF or depressed left ventricular function.
Christenson JT; Simonet F; Schmuziger M.; Economic impact of preoperative intraaortic balloon pump therapy in high-risk coronary patients. Ann Thorac Surg 2000 Aug;70(2):510-5
BACKGROUND:The efficacy of preoperative intraaortic balloon pump therapy in high-risk coronary patients has been demonstrated earlier.
METHODS:This study investigates the economic aspect by a detailed cost analysis of pooled information from two previously published randomized studies and 144 consecutive low-risk coronary artery bypass graft operations. Costs for patients receiving preoperative intraaortic balloon pump therapy before aortic cross-clamping (n = 62) were compared to those in a control group (n = 50). Detailed cost analysis was based on data provided by the hospital finance department.
RESULTS:The total hospital costs were as follows: low-risk coronary artery bypass graft operations cost 35,335+/-1,694 Swiss francs ($23,400+/-$1,121); high-risk coronary artery bypass graft without preoperative intraaortic balloon pump therapy cost 65,892+/-31,719 Swiss francs ($43,637+/-$21,006); and high risk coronary artery bypass graft with preoperative intraaortic balloon pump therapy cost 41,948+/-10,379 Swiss francs ($27,780+/-$6,874) (p = 0.0015). There were no significant differences in average cost among the preoperative intraaortic balloon pump therapy subgroups.
CONCLUSIONS:Preoperative intraaortic balloon pump therapy in high risk coronary patients is significantly cost-beneficial, With an average saving of 24,000 Swiss francs ($16,000) on the total hospital cost, a 36% cost reduction.
Rosen AB; Humphries JO; Muhlbaier LH; Kiefe CI; Kresowik T; Peterson ED.; Effect of clinical factors on length of stay after coronary artery bypass surgery: results of the cooperative cardiovascular project. Am Heart J 1999 Jul;138(1 Pt 1):69-77
BACKGROUND:Rising health care costs have prompted careful review of comparative hospital resource use. Length of stay after bypass surgery has received particular attention. However, many providers assert that these variations are caused by differences in the clinical mix of patients treated. Our goals were to identify the major clinical predictors of postoperative length of stay (PLOS) after coronary artery bypass graft surgery (CABG), document variations in PLOS among 28 hospitals, and assess the degree to which patient characteristics account for hospital variations in PLOS.
METHODS:Detailed clinical data on 3605 Medicare patients undergoing CABG in 28 Alabama and Iowa hospitals were analyzed by stepwise linear regression to identify significant clinical predictors of PLOS. Analysis of variance was used to compare hospitals' PLOS while controlling for significant patient risk factors. RESULTS: The mean age was 72.1 years, 34.7% were female, and the in-hospital mortality rate was 5.6%. The median and mean PLOS were 8 and 11.1 days, respectively. Significant predictors of longer PLOS included increasing age, female sex, history of chronic obstructive pulmonary disease, cerebrovascular disease, or mitral valve disease, elevated admission blood urea nitrogen, and preoperative placement of an intraaortic balloon pump. Hospitals varied significantly (P =.0001) in their unadjusted PLOS. These hospital-level variations persisted despite adjustment for both preoperative patient characteristics (P =.0001) and postoperative complications and death (P =.0001).
CONCLUSIONS:This study found significant between-hospital variations in PLOS that were not explained by patient factors. This finding suggests the potential for increased efficiency in the care of patients undergoing CABG at many institutions. Further research is needed to determine the practice patterns contributing to variations in length of stay after bypass surgery.
Shin H, Yozu R, Sumida T, Kawada S.; Acute ischemic hepatic failure resulting from intraaortic balloon pump malposition. Eur J Cardiothorac Surg 2000 Apr;17(4):492-4
We describe a rare intraaortic balloon pump (IABP) vascular complication as a result of malpositioning of the IABP. A 61-year-old man with unstable angina underwent emergency coronary artery bypass grafting soon after the insertion of an IABP. Postoperative hemodynamics were stable, but acute hepatic dysfunction occurred on the second postoperative day. Doppler echography revealed the absence of hepatic arterial flow. The IABP was removed, and arterial flow was immediately restored. Thereafter, the hepatic function recovered rapidly. This is a rare case that demonstrates how IABP can cause mechanical abdominal arterial branch obstruction. Evaluations using Doppler echography are useful in detecting such IABP complications.
Holman WL, Li Q, Kiefe CI, McGiffin DC, Peterson ED, Allman RM, Nielsen VG, Pacifico AD.; Prophylactic value of preincision intra-aortic balloon pump: analysis of a statewide experience. J Thorac Cardiovasc Surg 2000 Dec;120(6):1112-9
OBJECTIVE:The objective of this study was to determine whether preincision use of an intra-aortic balloon pump improves survival and shortens postoperative length of stay in hemodynamically stable, high-risk patients undergoing coronary artery bypass grafting.
METHODS:A post hoc analysis of the Alabama CABG Cooperative Project database was performed by using propensity scores to model the likelihood of receiving a prophylactic preincision intra-aortic balloon pump. Every patient receiving a prophylactic preincision balloon pump was matched with another patient of similar propensity score who did not receive one. We then compared outcomes for matched pairs.
RESULTS:There were 7581 patients of whom 592 received a prophylactic preincision balloon pump. Patients with preoperative renal insufficiency, heart failure, or left main coronary artery disease, or who had undergone previous bypass grafting were significantly more likely to receive a prophylactic preincision balloon pump. By using propensity scores, we matched 550 patients who received a prophylactic preincision balloon pump with 550 who did not. Survival did not significantly differ by whether a prophylactic preincision balloon pump was used. However, surviving patients who received a preincision balloon pump had a significantly shorter postbypass length of stay (7 +/- 7.3 days) than did matched patients not receiving a balloon pump (8 +/- 6.2 days; P <.05).
CONCLUSIONS:No survival advantage was found for use of a prophylactic intra-aortic balloon pump in hemodynamically stable, high-risk patients undergoing bypass grafting, as opposed to placing a balloon pump on an "as needed" basis during or after the operation. However, the patients receiving the balloon pump had improved convalescence as shown by significantly shorter length of stay.
Sanborn TA; Sleeper LA; Bates ER; Jacobs AK; Boland J; French JK; Dens J; Dzavik V; Palmeri ST; Webb JG; Goldberger M; Hochman JS.; Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize Occluded Coronaries for cardiogenic shock? J Am Coll Cardiol 2000 Sep;36(3 Suppl A):1123-9
OBJECTIVE:We sought to investigate the potential benefit of thrombolytic therapy (TT) and intra-aortic balloon pump counterpulsation (IABP) on in-hospital mortality rates of patients enrolled in a prospective, multi-center Registry of acute myocardial infarction (MI) complicated by cardiogenic shock (CS).
BACKGROUND:Retrospective studies suggest that patients suffering from CS due to MI have lower in-hospital mortality rates when IABP support is added to TT. This hypothesis has not heretofore been examined prospectively in a study devoted to CS.
METHODS:Of 1,190 patients enrolled at 36 participating centers, 884 patients had CS due to predominant left ventricular (LV) failure. Excluding 26 patients with IABP placed prior to shock onset and 2 patients with incomplete data, 856 patients were evaluated regarding TT and IABP utilization. Treatments, selected by local physicians, fell into four categories: no TT, no IABP (33%; n = 285); IABP only (33%; n = 279); TT only (15%; n = 132); and TT and IABP (19%; n = 160). RESULTS: Patients in CS treated with TT had a lower in-hospital mortality than those who did not receive TT (54% vs. 64%, p = 0.005), and those selected for IABP had a lower in-hospital mortality than those who did not receive IABP (50% vs. 72%, p < 0.0001). Furthermore, there was a significant difference in in-hospital mortality among the four treatment groups: TT + IABP (47%), IABP only (52%), TT only (63%), no TT, no IABP (77%) (p < 0.0001). Patients receiving early IABP (< or = 6 h after thrombolytic therapy, n = 72) had in-hospital mortality similar to those with late IABP (53% vs. 41%, n = 64, respectively, p = 0.172). Revascularization rates differed among the four groups: no TT, no IABP (18%); IABP only (70%); TT only (20%); TT and IABP (68%, p < 0.0001); this influenced in-hospital mortality significantly (39% with revascularization vs. 78% without revascularization, p < 0.0001).
CONCLUSIONS:Treatment of patients in cardiogenic shock due to predominant LV failure with TT, IABP and revascularization by PTCA/CABG was associated with lower in-hospital mortality rates than standard medical therapy in this Registry. For hospitals without revascularization capability, a strategy of early TT and IABP followed by immediate transfer for PTCA or CABG may be appropriate. However, selection bias is evident and further investigation is required.
Hasdai D; Califf RM; Thompson TD; Hochman JS; Ohman EM; Pfisterer M; Bates ER; Vahanian A; Armstrong PW; Criger DA; Topol EJ; Holmes DR Jr.; Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol 2000 Jan;35(1):136-43
OBJECTIVE:This study characterized clinical factors predictive of cardiogenic shock developing after thrombolytic therapy for acute myocardial infarction (AMI).
BACKGROUND:Cardiogenic shock remains a common and ominous complication of AMI. By identifying patients at risk of developing shock, preventive measures may be implemented to avert its development.
METHODS:We analyzed baseline variables associated with the development of shock after thrombolytic therapy in the Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. Using a Cox proportional hazards model, we devised a scoring system predicting the risk of shock. This model was then validated in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III) cohort.
RESULTS:Shock developed in 1,889 patients a median of 11.6 h after enrollment. The major factors associated with increased adjusted risk of shock were age (chi2 = 285, hazard ratio [95% confidence interval] 1.47 [1.40, 1.53]), systolic blood pressure (chi2 = 280), heart rate (chi2 = 225) and Killip class (chi2 = 161, hazard ratio 1.70 [1.52, 1.90] and 2.95 [2.39, 3.63] for Killip II versus I and Killip III versus I, respectively) upon presentation. Together, these four variables accounted for >85% of the predictive information. These findings were transformed into an algorithm with a validated concordance index of 0.758. Applied to the GUSTO-III cohort, the four variables accounted for > 95% of the predictive information, and the validated concordance index was 0.796.
CONCLUSIONS:A scoring system accurately predicts the risk of shock after thrombolytic therapy for AMI based primarily on the patient's age and physical examination on presentation.
Craver JM; Murrah CP; Elective intraaortic balloon counterpulsation for high-risk off-pump coronary artery bypass operations. Ann Thorac Surg 2001 Apr;71(4):1220-3
BACKGROUND:Dislocations of the heart required for exposure and construction of distal anastomoses often produce hemodynamic instability when performing coronary artery revascularization without using cardiopulmonary perfusion (OPCAB). We report our early experience with elective intraaortic balloon counterpulsation (IABP) to enable and facilitate selected high-risk patients to undergo OPCAB.
METHODS:Sixteen high-risk patients undergoing multivessel OPCAB using elective IABP are reported. The patients were believed to be at increased risk because of the presence of severe proximal multivessel coronary artery obstruction, ventricular dysfunction, recent acute myocardial infarction, cardiomegaly-cardiomyopathy, and documented cerebral vascular disease. The presence of significant comorbid disease also made the avoidance of cardiopulmonary bypass desirable, if at all possible, in all patients.
RESULTS:The IABP appeared to facilitate the intraoperative management of our series of patients. This was evidenced by improved hemodynamic stability and virtual elimination of the need for inotropic support during the dislocations of the heart needed for exposure and construction of distal anastomoses. There were no complications related to use of IABP. There was one death.
CONCLUSIONS:We believe this strategy to use IABP selectively can allow surgeons to safely extend the benefits of OPCAB procedures to high-risk patients and avoid dangerous hemodynamic instability that otherwise, often occurs.
Velez CA; Kahn J; Compartment syndrome from balloon pump. Catheter Cardiovasc Interv 2000 Oct;51(2):217-9
A 35-year-old man had significant left main coronary artery disease and required intra-aortic balloon catheter insertion owing to refractory ischemia before emergency coronary artery bypass graft. In the immediate postoperative period the patient started complaining of leg pain and diminished sensation in the right foot despite palpable pulses. The diagnosis of acute compartment syndrome of the right leg was made by an intracompartment pressure measurement of 90 mm Hg.
Arafa OE; Geiran OR; Andersen K; Fosse E; Simonsen S; Svennevig JL; Intraaortic balloon pumping for predominantly right ventricular failure after heart transplantation. Ann Thorac Surg 2000 Nov;70(5):1587-93
BACKGROUND:Right ventricular failure from elevated pulmonary vascular resistance in the recipient is a main cause of early mortality after heart transplantation. When pharmacologic treatment is insufficient, mechanical circulatory assistance has been used to support the failing right ventricle. Considering right and left ventricular interdependence, we investigated whether intraaortic balloon counterpulsation (IABP) might also alleviate predominantly right ventricular dysfunction after heart transplantation.
METHODS:Among 278 cardiac recipients, 12 adult patients underwent mechanical circulatory support for cardiac allograft dysfunction. Five patients were treated with percutaneous IABP for early postoperative low cardiac output syndrome characterized by predominantly right ventricular failure. Clinical data and hemodynamic variables were recorded before and during IABP treatment.
RESULTS:Cardiac index (CI) and mean arterial pressure (MAP) increased (CI 1.7 +/- 0.1 to 2.5 +/- 0.2, MAP 53 +/- 12 to 71 +/- 7, p < 0.05) within 1 hour after IABP, whereas central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) decreased (CVP 21.6 +/- 1.7 to 13.8 +/- 3.1, p < .05; PAWP 14.8 +/- 4.9 to 12.4 +/- 3.7, nonsignificant). Within the next 12 hours, CI and mixed venous oxygen saturation increased (p < 0.05) and pulmonary artery pressure decreased (p < 0.05). All 5 patients were weaned successfully and 4 are long-term survivors with adequate cardiac performance at 1 year follow-up.
CONCLUSIONS:Intraaortic balloon pumping is a minimally invasive circulatory assist device with proved efficiency in low cardiac output syndromes. This report shows that low output syndrome caused by predominantly right ventricular allograft failure may be an additional indication for IABP.
Kang N; Edwards M; Larbalestier R; Preoperative intraaortic balloon pumps in high-risk patients undergoing open heart surgery. Ann Thorac Surg 2001 Jul;72(1):54-7
BACKGROUND:The use of the preoperative intraaortic balloon pump (IABP) in patients with severe left ventricular dysfunction or unstable angina with critical coronary anatomy is becoming more frequent as surgical casemix changes. The aim of this study was to determine the impact of preoperative IABP use on survival in high-risk patients having open heart surgery.
METHODS:Prospectively collected data for 645 consecutive patients were reviewed. Patients receiving an IABP were identified and grouped as follows: group A (preoperative IABP for high-risk nonemergent cases), group B (preoperative IABP for emergent cases), and group C (intra/postoperative IABP). Risk-adjusted hospital mortality rates in these three groups was compared using the modified Parsonnet score for preoperative risk stratification.
RESULTS:IABPs were used in 101 cases (16%). The predicted versus actual hospital mortality rate was 20% versus 5.7% in group A, 32.1% versus 47.6% in group B, and 12.6% versus 22.2% in group C (group A vs group B, p = 0.0014; group A vs group C, p = 0.012). IABP-related morbidity occurred in 3% of cases (all in group C).
CONCLUSIONS:Risk-adjusted mortality was significantly lower in high-risk cases with preoperative IABPs compared with emergent cases and intraoperative/postoperative IABPs. We encourage the use of preoperative IABPs in selected high-risk patients.
Kim KB; Lim C; Ahn H; Yang JK; Intraaortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients. Ann Thorac Surg 2001 Jun; 71(6): 1964-8
BACKGROUND:Displacement of the heart to expose posterior vessels during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG, or OPCAB) may impair cardiac function. We used the intraaortic balloon pump (IABP) preoperatively to reduce operative risk and to facilitate posterior vessel OPCAB in high-risk patients with left main coronary artery disease (> 75% stenosis), intractable resting angina, postinfarction angina, left ventricular dysfunction (ejection fraction < 35%), or unstable angina.
METHODS:One hundred and forty-two consecutive patients who underwent multivessel OPCAB including posterior vessel revascularization were studied prospectively. The patients were divided into group I (n = 57), which received preoperative or intraoperative IABP, and group II (n = 85), which did not receive IABP. In group I, there were 34 patients with left main coronary artery disease, 24 patients with intractable resting angina, 8 patients with left ventricular dysfunction, 5 patients with postinfarction angina, and 40 patients with unstable angina. Seven patients received intraoperative IABP support owing to hemodynamic instability during OPCAB.
RESULTS:There was no operative mortality in group I and 1 death in group II. The average number of distal anastomoses was not different between group I and group II (3.4 +/- 0.9 versus 3.5 +/- 0.9, p = not significant). There were no significant differences in the number of posterior vessel anastomoses per patient. There were no differences in ventilator support time, length of stay in the intensive care unit, hospital stay, and morbidity between the two groups. There was one IABP-related complication in group I.
CONCLUSIONS:IABP therapy facilitates posterior vessel OPCAB in high-risk patients, and surgical results are comparable with those in lower-risk patients.
Menon V; Hochman JS; Stebbins A; Pfisterer M; Col J; Anderson RD; Hasdai D; Holmes DR; Bates ER; Topol EJ; Califf RM; Ohman EM; Lack of progress in cardiogenic shock: lessons from the GUSTO trials. Eur Heart J 2000 Dec;21(23):1928-36
OBJECTIVES:We used the GUSTO-I and GUSTO-III databases to evaluate our performance in treating cardiogenic shock patients over much of the 1990s.
METHODS &; RESULTS:GUSTO-I (1990-1993) and GUSTO-III (1995-1997) prospectively identified all patients with cardiogenic shock complicating acute myocardial infarction. Demographics, clinical presentation and outcomes for cardiogenic shock patients in the two trials were compared. Only patients enrolled with cardiogenic shock in countries common to both trials were included in these analysis. The 695 patients with cardiogenic shock in GUSTO-III were compared with the 2814 patients with cardiogenic shock in GUSTO-I. GUSTO-III patients were older (P=0.0001) and more likely to be diabetic (P=0.009) and hypertensive (P=0.025). They had a higher Killip class (P=0.002) and significantly greater index anterior infarction than cardiogenic shock patients enrolled in GUSTO-I. Time to treatment, presentation heart rate, and diastolic blood pressure were similar; however, systolic blood pressure at presentation was higher among GUSTO-III patients (P=0.002). Rates of coronary angiography, pulmonary artery catheterization, and mechanical ventilation declined in GUSTO-III compared with GUSTO-I (P=0.001); rates of angioplasty and bypass surgery were similar. Cardiogenic shock mortality in GUSTO-III was significantly higher than in GUSTO-I (62 vs 54%, P=0.001), as were rates of reinfarction (14 vs 11%, P=0.013) and recurrent ischaemia (35 vs 27%, P=0.00001). Mortality at non-U.S. sites (68 and 64%) was higher than at U.S. sites (53 and 50%) in both GUSTO-I and GUSTO-III studies, respectively. Angioplasty, bypass surgery, and balloon pump rates were lower for non-U.S. patients.
CONCLUSIONS:Cardiogenic shock continues to be associated with high mortality in thrombolytic-treated patients. Lower mortality observed in the U.S.A. supports consideration for percutaneous and surgical revascularization. Copyright 2000 The European Society of Cardiology.
Comparison of Outcomes After 8 vs. 9.5 French Size Intra-Aortic Balloon Counterpulsation Catheters Based on 9,332 Patients in the Prospective Benchmark® Registry Marc Cohen, MD, James Ferguson lll, MD, Robert J. Freedman, Jr. MD, Michael F. Miller, PhD, Ramachandra C. Reddy, MD, Magnus Ohman, MD, Gregg Stone, MD, Jan Christenson, MD, and Debra L. Joseph, RN on behalf of Benchmark Registry Collaborators
The Benchmark intra-aortic balloon counterpulsation (IABC) registry maintains prospectively gathered clinical information on a large cohort of IABC patients. The purpose of the present report is to compare in-hospital outcomes and complications in patients treated with the newer 8 vs. 9.5 Fr size catheters. Between January 1997 and August 2000 data on 7,078 9.5 Fr and 2, 254 8 Fr IABC insertions were submitted to Benchmark. This was not a randomized comparison but rather a posthoc analysis of prospectively gathered data. There was less limb ischemia with the 8 Fr IABC size catheter. There were no significant differences in bleeding or mortality between the two groups. Smaller IABC catheter size is associated with significantly less limb ischemia, especially in higher-risk patients. The large, population-based, ongoing Benchmark registry provides a useful vehicle for outcomes research concerning evolving practice of IABC. Cathet Cardiovasc Intervent 2002;56:200-206.
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