IABP

Houghton 3/6/2014

Disclosure’s

• I don’t like IABP’s

Am J Cardiology Review Article (2006) – great for general principles, complications, indications

Indications ??? Cardiogenic shock (left ventricular failure or mechanical complications of an acute myocardial infarction)? Intractable angina● Low cardiac output after cardiopulmonary bypass?? Adjunctive therapy in high risk or complicated angioplasty ?? Prophylaxis in patients with severe left main coronary arterial stenosis in whom surgery is pending? Intractable myocardial ischemia awaiting further therapy ● Refractory heart failure as a bridge to further therapy● Intractable ventricular arrhythmias as a bridge to further therapy.

AHA Class IIa -2004 The use of prophylactic intra-aortic balloon pump as an adjunct to myocardial protection is probably indicated in patients with evidence of ongoing myocardial ischemia and/or patients with a subnormal cardiac index. (Level of Evidence: B)

Prophylactic use of intra-aortic ballon pump in aortocoronary bypass for patients with left main

coronary artery disease.

• Ann Surg. 1978 Feb;187(2):118-21.• Patients: 20 patients with LM stenosis >50%, 50%

patients unstable angina• Results: 0 patients died, 1 had postoperative MI• Conclusions: “Prophylactic intra-aortic balloon

pumping is a low risk procedure that should be utilized routinely in aortocoronary bypass surgery for left main coronary artery disease”

A Randomized Controlled Trial of Preoperative Intra-Aortic Balloon Pump in Coronary Patients With Poor Left Ventricular

Function Undergoing Coronary Artery Bypass Surgery

• Critical Care Medicine 2013 PMID: 23921278

• Patients: 110, LVEF (< 35%), HD stable• Methods: IABP placed immediately preoperatively• Results: No difference in 30 day mortality, IABP required less

intraoperative dopamine

Elective intra-aortic balloon counterpulsation during high-risk percutaneous coronary intervention: a

randomized controlled trial (BCIS-1)

• JAMA. 2010 PMID 20736470

• Patients: 301 with LVEF <30%, severe CAD (by jeopardy score)

• Methods: prophylactic IABP prior to PCI vs none• Results: No difference in MACCE at discharge, No

difference in all-cause mortality at 6 months

Long-term mortality data from the balloon pump-assisted coronary intervention study (BCIS-1): a randomized, controlled

trial of elective balloon counterpulsation during high-risk percutaneous coronary intervention.

• Circulation 2013 PMID 23224207

• Patients: 301 with LVEF <30%, severe CAD (by jeopardy score)• Methods: prophylactic IABP prior to PCI vs none• Results: All-cause mortality at 51 months was 33% in the

overall cohort, with significantly fewer deaths occurring in the elective IABP group (n=42) than in the group that underwent PCI without planned IABP support (n=58) (hazard ratio, 0.66; 95% confidence interval, 0.44-0.98; P=0.039)

Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock

• Cochrane Database Syst Rev. 2011 PMID: 21735410

• Criteria: Randomized controlled trials on patients with myocardial infarction complicated by cardiogenic shock.

• Results: Data from a total of 190 patients with acute myocardial infarction and cardiogenic shock were included in the meta-analysis– HR's for all-cause 30-day mortality of 1.04 (95% CI 0.62 to

1.73) provides no evidence for a survival benefit.

Intraaortic balloon support for myocardial infarction with cardiogenic shock. (IABP-SHOCK)

• N Engl J Med 2012 PMID 22920912

• Patients: 600 patients with cardiogenic shock complicating acute myocardial infarction

• Results: IABP did not significantly reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned, no differences in secondary outcomes

Fun Facts

• In non-heparinized experimental animals, an immobile, deflated balloon is subject to thrombosis within 20 minutes

• The largest IABP device manufacturer recommends that an immobile IABP device be removed within 30 minutes

• The most commonly used triggers are (1) the electrocardiographic (ECG) waveform and (2) the systemic arterial pressure waveform

• Helium gas is used inside balloon b/c it facilitates rapid transmission from console to balloon

Where is the IABP?

Conclusion• I don’t like IABP’s• Multiple RCT’s within past 5 years regarding

IABP’s• Many demonstrating lack of convincing evidence

for its use depending on precise indication• AHA Guidelines are out of date in light of recent

paper’s and not mentioned in most recent guidelines– 2011 ACCF/AHA Guideline for CABG– ACC/AHA 2004 Guidelines for CABG