Primary intra aortic balloon pump

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Primary Intra-Aortic Balloon Pump (P IABP)

• ANWER GHANI
• FIBMS
• IRAQ

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Primary Intra-Aortic Balloon Pump (P IABP) means
the use of IABP before inotropes for cardiogenic
Shock (CS).
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• The overall haemodynamic effects of IABP therapy

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IABP IN CS

• The overall hospital survival of patients with
  reported CS was 40.2. (1)

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IABP IN CS

• Hospital survival rate of patients with (any) MCS
  is higher than in patients without (survival any
  MCS 44.8 medical treatment 39.5). (1)

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IABP IN CS

• Survival of patients on MCS was significantly
  different between the devices (survival IABP
  49.5 pVAD 36.2 VA-ECMO 30.5. (1)
• (MCS) mechanical circulatory support

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IABP IN CS

• Survival IABP 49.5. (1)
• It should be borne in mind that IABP patients are
  more risky than inotropes patients. However, it
  achieves a higher rate of survival.

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IABP IN CS

• Highest overall survival was detected in patients
  with IABP in comparison to other MCS. (1)

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IABP IN CS

• The hospital survival rates of patients with IABP
  were significantly higher than for patients with
  other MCS or for patients with medical therapy.
  (1)

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IABP IN NICSNICS Non ischemic CS

• ?SvO2 was higher in the IABP group compared to
  intopes (17 vs. 5 ). (2)
• (SvO2) mixed-venous oxygen saturation to assess
  organ perfusion.

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IABP IN NICS

• IABP patients had a higher ?CPO in comparison to
  Inotropes patients. (2)
• (CPO) cardiac power output

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IABP IN NICS

• IABP patients had a a greater relative reduction
  in NT-proBNP in comparison to Inotropes patients.
  (2)

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IABP IN NICS

• IABP patients had a more negative cumulative
  fluid balance in comparison to Inotropes
  patients. (2)

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IABP IN NICS

• IABP patients had a greater reduction in
  dyspnoea severity score. in comparison to
  Inotropes patients. (2)

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IABP IN NICS

• There were no IABP-related serious adverse
  events (SAEs). (2)

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IABP IN NICS

• Thirty-day mortality was 23 (IABP) vs. 44
  (INO). (2)
• THIS IS SO IMPORTANT

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IABP IN ICSICS Ischemic CS

• The predominant benefit of IABP on high-risk
  patients with severe coronary stenosis may relate
  to a reduction in oxygen demand through LV
  systolic unloading over and above that stimulated
  by diastolic augmentation of the coronary blood
  flow. (3)

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IABP IN ICS

• By decreasing LV end-diastolic pressure
  following an unloading of the LV, IABP decreases
  the LV wall tension and LV transmural pressure.
  (3)

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IABP IN ICS

• Few studies are available concerning the use of
  IABP compared to standard of care (noradrenalin,
  dobutamine, and intensive care unit management)
  or Impella mechanical support device.(3)

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IABP IN ICS
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IABP IN ICS

• Cardiogenic shock complicating myocardial
  infarction in the thrombolytic era, IABP was
  mainly implanted in patients with haemodynamic
  instability or CS with overall favourable results
  in registries or small randomized trials. (4)

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IABP IN ICS

• IABP wide use has been in part related to the
  Class I recommendation set in the previous
  European and American guidelines, despite a level
  of evidence of C and B respectively due to the
  small sample size of the supporting studies
  (mostly observational). (4)
• Today, IABP usage has a class IIb recommendation
  in the American guidelines and a class III
  recommendation in the European guidelines
  according to IABP SHOCK II study and others.

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IABP IN ICS

• IABP-SHOCK II is currently the largest available
  randomized clinical trial investigating the role
  of IABP in patients with AMI and CS, and the
  authors should be commended for their efforts.
  However, several study limitations are evident.
  (4)

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IABP IN ICS

• However, all the aforementioned studies were not
  adequately powered either to investigate an
  association between IABP and mortality as a
  single Endpoint or to draw definite conclusions.
  (4)

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IABP IN ICS

• The neutral results of the IABP-SHOCK II trial
  might be related to a late IABP implantation,
  which occurred in the vast majority of cases
  after PCI. (4)
• Today, IABP usage has a class IIb recommendation
  in the American guidelines and a class III
  recommendation in the European guidelines
  according this study and others.

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IABP IN ICS

• The insertion of IABP before PCI was associated
  with a significant reduction in mortality and
  adverse cardiovascular events. (4)

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IABP IN ICS

• Recently, a study including patients with CS due
  to different aetiologies, confirmed that an early
  placement of IABP was an independent predictor of
  30 days survival. (4)

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IABP IN ICS

• In a subgroup analysis of the CRISP-AMI trial in
  patients with large anterior STEMI and persisting
  ischaemia after PCI, the use of IABP was
  associated with a significant mortality reduction
  at 6 months. (4)

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IABP IN ICS

• In Hawranek et al. (7200 patients with AMI
  complicated by CS)
• Patients treated with IABP presented lower
  systolic arterial pressure and LVEF, higher heart
  rate, rate of multivessel coronary artery
  disease, and involvement of left main and left
  anterior descending artery.
• The use of IABP was associated with higher 30-day
  and 1-year mortality, recurrent MI, stroke,
  recurrent PCI, major bleeding, and cardiac
  arrest, due to the higher risk profile of
  patients treated with the device. However, in
  patients with final TIMI flow 0/1, IABP use was
  an independent predictor of lower 30-days
  mortality .

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IABP IN ICS

• The use of IABP should be considered in the very
  early phases of CS and in patients with impending
  shock. (4)

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IABP IN ICS

• Therefore, it is crucial to timely identify
  patients who are at risk of developing CS (or in
  CS initial phase) searching for early signs of CS
  such as initial increase in lactate levels in a
  setting of organ hypoperfusion. (4)

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IABP IN ICS

• It seems reasonable to proceed with IABP
  implantation in patients with impending shock/CS,
  provided it is implanted in the very early phases
  of heart failure/CS. (4)

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Conclusions

• We need
• 1- more and big studies about IABP.
• 2- more targets other than mortality.
• 2- Early IABP use.
• IABP looks more useful than we think.

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Reference

• 1-Corinna N. Lang et al Cardiogenic shock
  incidence, survival and mechanical circulatory
  support usage 20072017-insights from a national
  registry. Clin Res Cardiol. 2021 110(9)
  14211430.
• 2- Corstiaan A den Uil 1et al Primary
  intra-aortic balloon support versus inotropes for
  decompensated heart failure and low output a
  randomised trial.- EuroIntervention 2019 Sep
  2015(7)586-593.
• 3-Florian Rey et al Intra-Aortic Balloon Pump
  and Ischemic Cardiogenic Shock May Still Be a
  Valuable Association. J Clin Med. 2021 Feb
  10(4) 778.
• 4- Roberta Rossini ET AL ANMCO POSITION PAPER
  Role of intra-aortic balloon pump in patients
  with acute advanced heart failure and cardiogenic
  shock.Eur Heart J Suppl. 2021 Aug.

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THANKS