Non-Coronary Intervention Circulatory Support

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Non-Coronary InterventionCirculatory Support

• Advanced Angioplasty 2003

Andreas Baumbach Bristol Royal Infirmary
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Circulatory Support

• PCI / Acute MI
• Cardiogenic shock

Cardiac Surgery High risk CABG Weaning Bridge to
transplant Chronic Heart Failure ?
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Circulatory Support

• Balloon Counterpulsation
• Results Evidence
• Guidelines
• Assist Devices Developments

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Intra-Aortic Balloon Pump

• Inflatable 32-40 cc balloon
• Triggered to inflate with helium immediately
  after aortic valve closure
• Triggered to deflate with opening of the aortic
  valve

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Intra-Aortic Balloon Pump
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Intra-Aortic Balloon Pump

• Decreases Afterload
• Increases Diastolic Aortic Pressure
• Increases Coronary Flow Velocity
• Reduces Myocardial Oxygen Demand

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Circulatory Support

• Balloon Counterpulsation
• Results Evidence
• Guidelines
• Assist Devices Developments

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Intra-Aortic Balloon PumpCurrent Practice

• Results from the Benchmark Registry
• Ferguson et al. J Am Coll Cardiol 2001 381456

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Benchmark Registry

• June 96-August 2000
• 203 Hospitals (90US)
• 16909 patient case records
• Verified by external audit

Ferguson et al. J Am Coll Cardiol 2001 381456
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Benchmark Registry Indication

• Hemodynamic support during/after catheterisation
  20.6
• Cardiogenic shock 18.8
• Weaning from CP bypass 16.1
• Preoperative use in high risk pts 13
• Refractory unstable angina 12.3

Ferguson et al. J Am Coll Cardiol 2001 381456
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Benchmark Registry Complications

• Major Limb ischemia, severe bleeding, balloon
  leak, death due to IABP 2.6
• In hospital mortality 21.2
• Failed IABP insertion 2.3
• Increased risk for major complications
• Women
• Low BSA
• Older patients
• PVD

Ferguson et al. J Am Coll Cardiol 2001 381456
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IABP Evidence

• A prospective randomized evaluation of
  prophylactic intraaortic balloon counterpulsation
  in high risk patients with acute MI treated with
  primary angioplasty
• Stone et al. J Am Coll Cardiol 1997

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IABP in direct angioplasty

• Hypothesis routine use of IABP after primary PCI
  reduces infarct related artery reocclusion
• Multicentre, randomised trial
• High risk patients randomised to 36 to 48hrs IABP
  or standard care

Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty

• High risk
• Agegt70yrs
• 3 vessel disease
• LVEFlt45
• SVG occlusion
• Persistent malignant arrhythmia
• Subotpimal result

Stents 1.3
Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty

• N1100 Angio for MI
• N 908 randomised
• N 437 high risk
• IABP 211 no IABP 226
• Established 86 Crossover 13

Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty
Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty
Complications
No difference in hemorrhagic complications or
vascular complications Significant difference in
stroke This finding may be due to chance ..
One intracranial hemorrhage developed after a
postinfarction patient was hit in the head with a
shovel while robbing the hospital nursery
Stone et al. J Am Coll Cardiol 1997
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IABP Evidence

• A randomized comparison of intraaortic balloon
  pumping after primary coronary angioplasty in
  high risk patients with acute MI treated
• Van t Hoft 1999, Eur Heart J

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IABP Evidence
N 238 over 3.5 years 118 IABP 120 no
IABP Primary endpoint Death, Re-MI, stroke,
EFlt30 at 6 months FU -gt 26 vs 26 No
difference in EF 8 major complications in IABP
group

Van t Hoft 1999, Eur Heart J
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IABP Evidence SHOCK

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 Sanborn et al. J Am Coll Cardiol 2000
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IABP Evidence SHOCK
Background National registry of MI suggests
lower mortality in pts treated with thrombolysis
followed by IABP (49) compared with thrombolysis
alone (69) GUSTO trend towards better outcome

Sanborn et al. J Am Coll Cardiol 2000 361123
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SHOCK Registry

• N 856 patients with cardiogenic shock in acute
  MI
• 36 participating centres
• Treatment
• No thrombolysis / no IABP 33
• IABP only 33
• Thrombolysis only 15
• Thrombolysis and IABP 19

Sanborn et al. J Am Coll Cardiol 2000 361123
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SHOCK Registry Mortality

p.005
plt.0001
Sanborn et al. J Am Coll Cardiol 2000 361123
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SHOCK Result
IABP vs. no IABP mortality after adjustement for
revascularisation p0.313 Use of IABP with or
without thrombolysis improves survival in pts
with cardiogenic shock because of the higher rate
of attempted revascularisation in the IABP group
Sanborn et al. J Am Coll Cardiol 2000 361123
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Circulatory Support

• Balloon Counterpulsation
• Results Evidence
• Guidelines
• Assist Devices Developments

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Guidelines
Emergency high risk PCI such as direct PCI for
acute MI can usually be performed without IABP or
CPS. However, it should be noted that in
patients with borderline hemodynamics, ongoing
ischemia, or cardiogenic shock, insertion of an
intra-aortic balloon just prior to coronary
instrumentation has been associated with improved
outcomes. Furthermore it is reasonable to obtain
vascular access in the contralateral femoral
artery prior to the procedure in patients in whom
the risk of hemodynamic compromise is high
AHA/ACC Guidelines for PCI, Circulation 2001
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Guidelines

• Recommendations for the use of IABP in the
  treatment of AMI
• Class I
• Cardiogenic shock not quickly reversed with
  pharmacological therapy as a stabilising measure
  for angiography and prompt revascularisation
• Acute MR or VSD as a stabilising therapy for
  angio and repair/ revascularisation
• Recurrent intractable ventricular arrhythmias
  with hemodynamic instability
• Refractory post MI angina as a bridge to
  revascularisation

AHA/ACC Guidelines for AMI, JACC 1996, Web
update 1999
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Guidelines
Recommendations for the use of IABP in the
treatment of AMI Class IIa Signs of hemodynamic
instability, poor LV , or persistent ischemia in
patients with large areas of myocardium at
risk Class IIb Following successful angioplasty
to prevent reocclusion Large areas at risk w/o
active ischemia
AHA/ACC Guidelines for AMI, JACC 1996
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Summary IABP

• Intra-Aortic Balloon Pump is an excellent tool
  for the management of hemodynamically unstable
  patients especially in the setting of acute MI

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Circulatory Support

• Balloon Counterpulsation
• Results Evidence
• Guidelines
• Assist Devices Developments

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Assist Devices Indications

• Cardiogenic shock in AMI
• Postsurgical myocardial dysfunction
• Acute cardiac failure from myocarditis
• Decompensated chronic heart failure

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Assist Devices Goals

• Bridge to transplantation
• Bridge to recovery
• Alternative to heart transplantation

Delgado et al Circulation 20021062046
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Devices

• Extracorporeal Assist (e.g.Thoratec/Abiomed)
• Implantable LV assist devices (Heartmate)
• Axial Flow pumps
• Totally implantable LVAD (Lion Heart)
• Total Artificial Heart (ABIOCOR)

Delgado et al Circulation 20021062046
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HeartmateTM
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Heartmate
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Heartmate
N129
Quality of life
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AbiocorTM
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AbiocorTM
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AbiocorTM
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AbiocorTM
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Assist Devices

• Progress in technology promises new surgical
  treatment options for end stage heart failure
• Our surgical colleagues should be pleased to
  finally have hearts that we wont fix with
  percutaneous intervention