Intraaortic Balloon Pump
After thrombolysis for myocardial infarction
The ability of intraaortic balloon counterpulsation to simultaneously increase coronary blood flow by raising diastolic pressure and reduce left ventricular stroke work by reducing systolic blood pressure is intuitively attractive in the setting of ischemic cardiogenic shock. However prior to the thrombolytic era treatment of myocardial infarction complicated by cardiogenic shock with IABP did not significantly improve outcome1. Recent trials have shown that treatment with IABP after thrombolytic therapy increases early patency rates2 and increases late patency when thrombolysis has not recanalised the infarct related artery within 60 minutes3. A retrospective nonrandomised analysis of composite data from several TIMI trials also suggested that IABP improves early recovery of left ventricular function4. When ischemic cardiogenic shock is treated with thrombolysis (in the absence of readily available angioplasty facilities), intraaortic counterpulsation also improves survival5. The improved survival of patients presenting with cardiogenic shock in the United States compared with other countries in the GUSTO II study has also been attributed at least partly to an increased use of intraaortic counterpulsation after thrombolysis6.
After primary angioplasty for myocardial infarction.
Early trials showed that IABP after PTCA for anterior MI reduced reocclusion rates 7. A further study which examined the role of IABP after rescue angioplasty or intracoronary thrombolytics found adjuvant IABP recurrent ischemia and reocclusion8. By prevention of these complications IABP was also found to be cost-effective in these circumstances 9. However a randomised trial of IABP in patients at ‘high risk’ of reocclusion after primary angioplasty (high risk: age > 70, TVD, LVEF < 45%, SVG occlusion, suboptimal result or persistent ventricular arrhythmias) found no benefit in prevention of reocclusion or death10.
For circulatory support in high-risk angioplasty.
IABP has been used for support in high-risk angioplasty and rotational atherectomy with very good outcomes11 12 13. An observational study comparing peripheral cardiopulmonary bypass (CPB) to IABP for support druing high-risk angioplasty found that CPB was more likely to be used for complete revascularisation of multivessel disease and was more successful but was associated with greater rate of vascular and bleeding complications14. No randomised study to compare the two has yet been performed.
IABP at Stanford.
IABP is commonly used for high-risk patients at Stanford.
References
1. O'Rourke MF, Norris RM, Campbell TJ, Chang VP, Sammel NL. Randomized controlled trial of intraaortic balloon counterpulsation in early myocardial infarction with acute heart failure. Am J Cardiol. 1981; 47:815-20.
2. Gurbel PA, Anderson RD, MacCord CS, Scott H, Komjathy SF, Poulton J, Stafford JL, Godard J. Arterial diastolic pressure augmentation by intra-aortic balloon counterpulsation enhances the onset of coronary artery reperfusion by thrombolytic therapy. Circulation. 1994; 89:361-5.
3. Kono T, Morita H, Nishina T, Fujita M, Onaka H, Hirota Y, Kawamura K, Fujiwara A. Aortic counterpulsation may improve late patency of the occluded coronary artery in patients with early failure of thrombolytic therapy. J Am Coll Cardiol. 1996; 28:876-81.
4. Ohman EM, Califf RM, George BS, Quigley PJ, Kereiakes DJ, Harrelson-Woodlief L, Candela RJ, Flanagan C, Stack RS, Topol EJ. The use of intraaortic balloon pumping as an adjunct to reperfusion therapy in acute myocardial infarction. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. Am Heart J. 1991; 121:895-901.
5. 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; 29:1454-8.
6. Holmes DR, Jr., Califf RM, Van de Werf F, Berger PB, Bates ER, Simoons ML, White HD, Thompson TD, Topol EJ. Difference in countries' use of resources and clinical outcome for patients with cardiogenic shock after myocardial infarction: results from the GUSTO trial [see comments]. Lancet. 1997; 349:75-8.
7. Ishihara M, Sato H, Tateishi H, Uchida T, Dote K. Intraaortic balloon pumping as the postangioplasty strategy in acute myocardial infarction. Am Heart J. 1991; 122:385-9.
8. 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; 90:792-9.
9. 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; 79:590-4.
10. Stone GW, Marsalese D, Brodie BR, Griffin JJ, Donohue B, Costantini C, Balestrini C, Wharton T, Esente P, Spain M, Moses J, Nobuyoshi M, Ayres M, Jones D, Mason D, Grines L, WW ON, Grines CL. A prospective, randomized evaluation of prophylactic intraaortic balloon counterpulsation in high risk patients with acute myocardial infarction treated with primary angioplasty. Second Primary Angioplasty in Myocardial Infarction (PAMI-II) Trial Investigators. J Am Coll Cardiol. 1997; 29:1459-67.
11. Kahn JK, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV, Hartzler GO. Supported "high risk" coronary angioplasty using intraaortic balloon pump counterpulsation. J Am Coll Cardiol. 1990; 15:1151-5.
12. O'Murchu B, Foreman RD, Shaw RE, 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.
13. Voudris V, Marco J, Morice MC, Fajadet J, Royer T. "High-risk" percutaneous transluminal coronary angioplasty with preventive intra-aortic balloon counterpulsation. Cathet Cardiovasc Diagn. 1990; 19:160-4.
14. Schreiber TL, Kodali UR, WW ON, Gangadharan V, Puchrowicz-Ochocki SB, Grines CL. Comparison of acute results of prophylactic intraaortic balloon pumping with cardiopulmonary support for percutaneous transluminal coronary angioplasty (PCTA). Cathet Cardiovasc Diagn. 1998; 45:115-9.
Michael Ward, M.B.B.S.