[S3-Guideline: Recommendations for intra-aortic balloon pumping in cardiac surgery]. / S3-Leitlinie "Einsatz der intraaortalen Ballongegenpulsation in der Herzchirurgie".

Although intra-aortic balloon pumping (IABP) is the most frequently used mechanical cardiac assist device in cardiothoracic surgery, there are only guidelines for substantive sections of aortic counterpulsation including prophylactic and postoperative use. In contrast, evidence-based recommendations are still lacking concerning intraoperative use, management, contraindication and other relevant issues. According to international surveys, important aspects of IABP usage show a wide variation in clinical practice. The results of a national questionnaire performed before initiation of this guideline confirmed these findings and demonstrated a clear need for the development of a consensus-based guideline. Therefore, the presented multidisciplinary S-3-guideline was developed under the direction of the German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, DGTHG) to make evidence-based recommendations for the usage of aortic counterpulsation after cardiothoracic surgery according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF) and the Medical Centre for Quality (Ärztliches Zentrum für Qualität - (ÄZQ)). Main topics discussed in this guideline involve IABP support in the prophylactic, preoperative, intraoperative and postoperative setting as well as the treatment of right heart failure, contraindications, anticoagulation, monitoring, weaning, and limitations of IABP therapy. The presented 15 key messages of the guideline were approved after two consensus meetings under moderation of the AWMF with participation of the German Society of Cardiology (DGK), German Society of Anaesthesiology and Intensive Care Medicine (DGAI), German Interdisciplinary Association for Intensive Care (DIVI) and the German Society for Cardiovascular Engineering (DGfK).

Intra-aortic balloon pump: indications, efficacy, guidelines and future directions.

PURPOSE OF REVIEW: The intra-aortic balloon pump (IABP) has been used as a cardiac assist device in various clinical situations since 1968 on the basis of the physiological principles and observational data, with little randomized data until recently. RECENT FINDINGS: Recently published randomized controlled trials (RCTs) and meta-analyses have demonstrated acceptable safety for IABP but have raised doubt over efficacy in acute myocardial infarction (MI) both with and without cardiogenic shock. RCTs and meta-analyses have provided limited and qualified support for the efficacy of IABP in high-risk percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). There remains only observational data to support the efficacy of IABP in other niche indications, including mechanical complications of MI (acute severe mitral regurgitation and ventricular septal rupture) and refractory ventricular arrhythmia. SUMMARY: Current randomized trial data and meta-analyses support the safety of IABP, but provide limited or no support for its efficacy in the treatment of high-risk MI, MI complicated by cardiogenic shock or the use of prophylactic IABP in high-risk PCI and CABG. Further studies to inform optimal patient selection, timing and use of associated therapies are required to characterize the role of IABP in contemporary practice and optimize outcome in high-risk patient subsets.

[Clinical teaching program: standardized operating procedure for intra-aortic balloon pump support].

Intra-aortic balloon pump (IABP) is one of the most important treatment strategies for patients with heart failure in the intensive care unit (ICU). To ensure quality of treatment, clinical preceptors must employ effective teaching strategies to acquaint nurses with the proper use of IABPs. Many nurses are hesitant to use IABPs due to lack of knowledge regarding their use. Classroom lectures and instruction manual-style materials are often ineffective strategies for teaching novice nurses to use IABPs properly and have resulted in unsatisfactory patient treatment quality. This study developed a creative, pithy rhyme to help nurses remember the key elements of IABP support as part of their IABP learning process. This innovative tool uses rhymes and mental images to instill critical information related to IABP use and help nurses become fluent IABP users.

Impact of the Change in ESC Guidelines on Clinical Characteristics and Outcomes of Cardiogenic Shock Patients Receiving IABP Therapy.

BACKGROUND: Intra-aortic balloon pump (IABP) counterpulsation provides mechanical support for patients with cardiogenic shock. The aim of the study is to evaluate the clinical characteristics and outcomes of patients with cardiogenic shock receiving IABP before and after the European Society of Cardiology (ESC) downgraded the use of IABP from a class I to a class IIb in 2012. METHODS: Data was obtained from the Acute Coronary Syndrome Israeli Survey (ACSIS) registry, a prospective observational national survey conducted once every two years. From a total of 15,200 patients with acute coronary syndrome (ACS), 524 patients were identified with acute myocardial infarction (AMI)-complicated with cardiogenic shock. The groups were further subdivided based on whether the IABP was implanted before or after the change in guideline recommendation. RESULTS: The study indicates a 24% reduction in IABP use since 2002. Until 2012, a reduction in clinical outcomes including 7-days, 30-days and in-hospital mortality, was observed in patients with IABP compared to the patients with conventional therapy. Conversely, after the ESC changed the guidelines, the clinical outcomes were not improved by IABP treatment. Additionally, the conventional therapy group presented with higher baseline ejection fraction, received less effective treatment, reperfusion and/or pharmacological therapy than patients with IABP. CONCLUSION: The use of IABP as management for cardiogenic shock has diminished over time since the guidelines were modified. After the change in guidelines, the use of IABP is restricted to high-risk, severely compromised and hemodynamically deteriorated patients hence limiting beneficial outcomes.

Nursing Management of Patients Requiring Acute Mechanical Circulatory Support Devices.

TOPIC: The growing use of acute mechanical circulatory support devices to provide hemodynamic support that has accompanied the increasing prevalence of heart failure and cardiogenic shock, despite significant improvement in the treatment of acute myocardial infarction. CLINICAL RELEVANCE: The critical care nurse plays a crucial role in managing patients receiving acute mechanical circulatory support devices and monitoring for potential complications. PURPOSE: To review the anatomical placement and mechanics of each type of device so that nurses can anticipate patients' hemodynamic responses and avoid complications whenever possible, thereby improving patients' clinical outcomes. CONTENT COVERED: Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation.

Percutaneous mechanical circulatory support devices in high-risk patients undergoing percutaneous coronary intervention: A meta-analysis of randomized trials.

BACKGROUND: Percutaneous mechanical circulatory support devices (pMCSDs) are increasingly used on the assumption (but without solid proof) that their use will improve prognosis. A meta-analysis was undertaken according to the PRISMA guidelines to evaluate the benefits of pMCSDs in patients undergoing high-risk percutaneous coronary intervention (hr-PCI). METHODS: We searched PubMed, EMbase, Cochrane Library, Clinical Trial.gov, and other databases to identify eligible studies. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for 30-day and 6-month all-cause mortality rates, reinfarction, and other adverse events using a random effect model. RESULTS: Sixteen randomized controlled trials (RCTs) were included in this study. In the pooled analysis, intra-aortic balloon pump (IABP) was not associated with a decrease in 30-day and 6-month all-cause mortality (RR 1.01 95% CI 0.61-1.66; RR 0.88 95% CI 0.66-1.17), reinfarction (RR 0.89 95% CI 0.69-1.14), stroke/transient ischemic attack (TIA) (RR 1.75 95% CI 0.47-6.42), heart failure (HF) (RR 0.54 95% CI 0.11-2.66), repeat revascularization (RR 0.73 95% CI 0.25-2.10), embolization (RR 3.00 95% CI 0.13-71.61), or arrhythmia (RR 2.81 95% CI 0.30-26.11). Compared with IABP, left ventricular assist devices (LVADs) were not associated with a decrease in 30-day and 6-month all-cause mortality (RR 0.96 95% CI 0.71-1.29; RR 1.23 95% CI 0.88-1.72), reinfarction (RR 0.98 95% CI 0.68-1.42), stroke/TIA (RR 0.45 95% CI 0.1-1.95), acute kidney injury (AKI) (RR 0.83 95% CI 0.38-1.80), or arrhythmia (RR 1.52 95% CI 0.71-3.27), but LVADs were associated with a decrease in repeat revascularization (RR 0.26 95% CI 0.08-0.83). However, LVADs significantly increased the risk of bleeding compared with IABP (RR 2.85 95% CI 1.72-4.73). CONCLUSIONS: Neither LVADs nor IABP improves short or long-term survival in hr-PCI patients. LVADs are more likely to reduce repeat revascularization after PCI, but to increase the risk of bleeding events than IABP.

[Support of damaged heart with the Impella pump]. / Ondersteuning van beschadigd hart met Impella-pomp.

Temporary mechanical circulatory support is increasingly used, particularly in patients with cardiogenic shock or during high-risk percutaneous coronary interventions. In the last five years there have been numerous developments in this field. Experience has been gained from usage of temporary heart pumps, and new pumps have arrived on the market. Until recently, the intra-aortal balloon pump was the standard treatment for patients with cardiogenic shock; however, results from the latest research into the effectiveness of this pump have rendered it less popular. An alternative modality is the Impella system. Since 2012, usage of a heart pump in cardiogenic shock treatment is reimbursed by healthcare insurers in the Netherlands. Recently, the FDA approved the Impella system for said indication.

[The use of preoperative intra-aortic balloon in myocardial revascularization surgery associated to severe ventricular dysfunction]. / O uso do balão intra-aórtico no pré-operatório de cirurgia de revascularização miocárdica, associada à disfunção ventricular grave.

OBJECTIVE: To evaluate the effectiveness of prophylactic intra-aortic balloon (IAB) in elective myocardial revascularization surgery (MRS), to prevent trans or post-operative infarction and reduce intra-hospital mortality in patients with low left ventricular ejection fraction. METHODS: Using a cohort study model, 239 patients with left ventricular ejection fraction < or = 40%, submitted to elective MRS with extracorporeal circulation (ECC) were evaluated from March 1995 to February 2001. RESULTS: Of these, 58 patients received preoperative IAB and the remainder underwent surgery without circulatory assistance (control group). The two groups of patients had similar characteristics regarding factors associated to the pertaining outcomes. There were five demises (8.6%) in the group with IAB and 21 (11.6%) in the control group (non-significant difference). There were 2 (3.4%) infarctions in the IAB group and 28 (15.5%) in the control group (p< 0.05), relative risk of 0.22 with an interval of confidence of 95% from 0.05 to 0.85. CONCLUSION: The use of pre-operative IAB can significantly reduce the risk of trans or post-operative acute myocardial infarction (AMI) in patients with decreased systolic function, without increasing vascular complications. In this same situation, the IAB does not significantly decrease mortality. Randomized studies are necessary to establish more precise conclusions.

Prognosis in cardiogenic shock after acute myocardial infarction in the interventional era.

OBJECTIVES: The purpose of this study is to describe the outcome in cardiogenic shock treated with aggressive reperfusion therapy and to identify factors predictive of in-hospital and long-term mortality. BACKGROUND: Cardiogenic shock is the most common cause of death in patients admitted to the coronary care unit. Although studies have reported lower mortality rates in shock treated with angioplasty, few studies have described a cohort of patients with shock who were not selected because they were most likely to benefit from reperfusion therapy. METHODS: A consecutive series of 200 patients admitted with acute myocardial infarction complicated by cardiogenic shock were studied. RESULTS: The in-hospital mortality rate was 53%. Variables with significant univariable association with in-hospital death included patency of the infarct-related artery, patient age, lowest cardiac index, highest arteriovenous oxygen difference and left main coronary artery disease. The most important independent predictors of in-hospital death were patency of the infarct-related artery, cardiac index and peak creatine kinase, MB fraction. The mortality rate in patients with patent infarct-related arteries was 33% versus 75% in those with closed arteries and 84% in those in whom arterial patency was unknown. Patients who survived to hospital discharge were followed up for a median of 2 years, with a mortality rate of 18% after 1 year. The best descriptors of the relation between these variables and postdischarge mortality included age, peak creatine kinase, ejection fraction and patency of the infarct-related artery. CONCLUSIONS: In a large consecutive series of patients with cardiogenic shock with complete follow-up, patency of the infarct-related artery was most strongly associated with in-hospital and long-term mortality. This finding supports an aggressive interventional strategy in patients with cardiogenic shock.

The current practice of intra-aortic balloon counterpulsation: results from the Benchmark Registry.

OBJECTIVES: This study presents clinical data from the first large registry of aortic counterpulsation, a computerized database that incorporates prospectively gathered data on indications for intra-aortic balloon counterpulsation (IABP) use, patient demographics, concomitant medication and in-hospital outcomes and complications. BACKGROUND: The intra-aortic balloon pump (IABP) is widely used to provide circulatory support for patients experiencing hemodynamic instability due to myocardial infarction, cardiogenic shock, or in very high risk patients undergoing angioplasty or coronary artery bypass grafting. METHODS: Between June 1996 and August 2000, 203 hospitals worldwide (90% U.S., 10% non-U.S.) collected 16,909 patient case records (68.8% men, 31.2% women; mean age 65.9 +/- 11.7 years). RESULTS: The most frequent indications for use of IABP were as follows: to provide hemodynamic support during or after cardiac catheterization (20.6%), cardiogenic shock (18.8%), weaning from cardiopulmonary bypass (16.1%), preoperative use in high risk patients (13.0%) and refractory unstable angina (12.3%). Major IABP complications (major limb ischemia, severe bleeding, balloon leak, death directly due to IABP insertion or failure) occurred in 2.6% of cases; in-hospital mortality was 21.2% (11.6% with the balloon in place). Female gender, high age and peripheral vascular disease were independent predictors of a serious complication. CONCLUSIONS: This registry provides a useful tool for monitoring the evolving practice of IABP. In the modern-day practice of IABP, complication rates are generally low, although in-hospital mortality remains high. There is an increased risk of major complications in women, older patients and patients with peripheral vascular disease.

Routine preoperative insertion of IABP in high-risk off-pump coronary artery bypass grafting.

The beneficial effects of intraaortic balloon pump (IABP) in coronary artery bypass graft surgery with cardiopulmonary bypass have been reported. However, whether preoperative insertion of IABP in high-risk off-pump coronary artery bypass grafting (OPCAB) has any beneficial effects remains to be established. We report our experience of preoperative insertion of IABP in OPCAB.

Support with intra-aortic balloon pump vs. Impella2.5® and blood flow to the heart, brain and kidneys - an experimental porcine model of ischaemic heart failure.

BACKGROUND: Cardiogenic shock as a complication to an acute myocardial infarction has an unacceptably high death rate that has not changed for the last 15years. Mortality is partly related to organ hypoperfusion and mechanical assist devices are used for the most severe cases but we do not know which assist device is the best option. Therefore, we have investigated how an IABP and an Impella®-pump influenced blood flow to the brain, heart and kidneys, in a closed-chest porcine model of severe left ventricular failure. METHODS: 13 pigs were anesthetised and left ventricular failure was induced by occluding the proximal LAD for 45min followed by 30min of reperfusion. Blood flow was measured in the carotid artery, the LAD, and the renal artery. The Impella® and IABP were inserted via the femoral arteries, and the two devices were tested individually and combined after induction of heart failure. RESULTS: Carotid- (p=0.01) and renal blood flow (p=0.045) were higher on Impella®-support, compared to no support. None of the devices altered the blood flow in the LAD. Cardiac power output (p<0.005) and left ventricular work (p<0.00) were also higher on Impella®-support compared to no support. CONCLUSION: Haemodynamics and blood flow to the brain and kidneys were significantly better on Impella®-support, suggesting that the Impella® is superior to the IABP in a state of ischaemia induced left ventricular failure. These data, however, needs to be confirmed in a proper clinical trial with patients in cardiogenic shock.

Prophylactic use of the intra-aortic balloon pump in high-risk cardiac patients undergoing noncardiac surgery: a decision analytic view.

OBJECTIVE: As the indications for the intra-aortic balloon pump (IABP) continue to evolve, a potential new use may be the prophylactic preoperative insertion of the IABP in the high-risk cardiac patient undergoing noncardiac surgery. Our objective is to present a general approach to the high-risk cardiac patient who may benefit from the prophylactic insertion of the IABP. DESIGN: Case reports and a decision analysis. METHODS: A decision model was constructed that weighs the risk of life-threatening postoperative complications against the risk of vascular complications, including surgery and possible amputation, from IABP insertion. RESULTS AND CONCLUSIONS: A review of the literature identified 10 patients who underwent IABP placement prior to noncardiac surgery. These patients, along with our three cases, define a population of patients for whom the prophylactic IABP may be useful. This population includes patients with coronary artery disease (CAD) for whom bypass grafting is not an option due to: (1) inoperable CAD; (2) a severe coexisting disease process (such as a malignancy); or (3) the emergent nature of the noncardiac procedure. The decision analysis suggests that patients whose preoperative assessment places them at very high risk for postoperative complications (Goldman class IV or Detsky class III undergoing major surgery) may benefit the most from prophylactic placement of an IABP prior to noncardiac surgery.

Effect of intra-aortic balloon counterpulsation on right-left shunt following right ventricular infarction.

Intra-aortic balloon counterpulsations decrease the left ventricular end-diastolic pressure and, subsequently, the left atrial pressure in patients with impaired myocardial function following myocardial infarction. This paper reports a case of right ventricular infarction in a patient with patency of the oval foramen where the use of intra-aortic balloon counterpulsation led to the perpetuation of the right-to-left shunt.

Retroperfusion and balloon support to improve coronary revascularization.

Coronary venous retroperfusion and Intra-Aortic Balloon Pump (IABP) support are methods currently utilized to reduce ischemic damage prior to revascularization of acutely ischemic myocardium. This study was undertaken to determine whether combining coronary venous retroperfusion using Pressure Controlled Intermittent Coronary Sinus Occlusion (PICSO) with the IABP would result in improved salvage of ischemic myocardium. In 40 adult pigs, the second and third diagonal vessels were occluded with snares for 1 1/2 hours followed by 1/2 hours of cardioplegic arrest and 3 hours of reperfusion with the snares released. During the period of coronary occlusion prior to arrest, 10 pigs received the IABP, 10 had PICSO, 10 had PICSO+IABP, while 10 had no intervention (Unmodified). Ischemic damage was assessed by echocardiographic wall motion scores, myocardial pH, and the area of necrosis/area of risk using histochemical staining. Both PICSO and the IABP alone significantly reduced ischemic damage. However, the best wall motion scores, highest pH, and least necrosis was seen in the IABP+PICSO group. We conclude that the combination of coronary venous retroperfusion using PICSO and the IABP results in the most optimal recovery of acutely ischemic myocardium during emergent surgical revascularization.

Juxtaaortic counterpulsation: comparison with intraaortic counterpulsation in an animal model of acute heart failure.

This study was designed to compare the effects of juxtaaortic balloon counterpulsation (JABC), performed in ascending aorta and the aortic arch, with those yielded by intraaortic balloon counterpulsation (IABC) in descending aorta, in experimental animals during induced cardiac failure. JABC was achieved with a manufactured Dacron prosthesis and a balloon pump placed between the prosthesis and the wrapped aorta. JABC resulted in a significant increase of cardiac output (from 2.33+/-0.82 to 2.61+/-1.12 L/min, p < 0.05), cardiac index (from 0.071+/-0.025 to 0.080+/-0.033 L/min/kg, p < 0.05) and diastolic pressure augmentation evaluated through diastolic and systolic areas beneath the aortic pressure curve (DABAC/SABAC) index (from 0.94+/-0.21 to 1.10+/-0.33, p < 0.01). End diastolic aortic pressure showed a significant decrease with JABC (from 31.90+/-7.09 to 27.83+/-9.72 mm Hg, p < 0.05). A close association between percentage of DABAC/SABAC increases obtained with IABC and JABC was observed (r2 = 0.67; p < 0.001). Counterpulsation obtained by a juxtaaortic catheter placed in the arch and the ascending wrapped aorta results in an effective hemodynamic improvement comparable with that achieved by an intraaortic catheter in open chest sheep.

Estimation of timing errors for the intraaortic balloon pump use in pediatric patients.

The use of the intraaortic balloon pump (IABP) for managing acute left ventricular failure in pediatric patients is less successful than in adults. It is often reported that rapid pediatric heart rates make accurate timing difficult to achieve. Traditional IABP theory requires that the balloon inflate during diastole (after aortic valve closure), for optimum coronary pressure and flow augmentation, and deflate just before the next systole for optimal ventricular afterload reduction. Errors in timing balloon inflation and deflation may result in the reduced IABP efficacy seen in children. To investigate timing errors when using the traditional IABP inflation and deflation markers in pediatric patients, six patients (age, 2.2+/-1.4 years; weight, 11.5+/-3.9 kg) were studied intraoperatively. Radial artery pressure (RAP) waveforms from a standard, fluid-filled pressure monitoring system were recorded on an FM data tape recorder simultaneously with high-fidelity, aortic root pressure waveforms, aortic root flow waveforms, and M-mode echocardiography. For each patient, a sequence of five recorded waveforms was analyzed. The mean +/- standard deviation of the time delay between aortic root and RAP markers and percentage delay of the corresponding part of the cardiac cycle were determined. When compared with aortic root waveforms, the RAP waveform consistently showed a delay in the IABP timing markers. A 107+/-23 msec (53+/-11%) delay in diastolic inflation and a 92+/-11 msec (40+/-4%) delay in presystolic deflation was found. If IABP timing to the RAP markers were to be used, the delay in IABP inflation would result in reduced diastolic augmentation, and the delay in IABP deflation into the systolic period would increase afterload. M-mode echocardiography provided timing markers that were identical to those provided by high-fidelity aortic root pressure waveforms. The combined effect of these delays on IABP function could substantially reduce the efficacy of the IABP in pediatric patients, indicating the need for more accurate indices for IABP timing in this patient group.

[The efficacy of the intra-aortic balloon pump for patients with heart failure complicating acute myocardial infarction (author's transl)]. / Die Effektivität der intraaortalen Ballonpumpe bei Patienten mit Herzinsuffizienz durch akuten Myokardinfarkt.

Assisted circulation was carried out with the help of an intra-aortic balloon pump in 22 patients with acute transmural myocardial infarction and heart failure (despite medication). Two patients died in hospital. The combination of the balloon pump and nitrates proved to be particularly effective. The follow-up examination of the survivors showed a distinct pulmonary arterial pressure during ergometry. All of the examined patients revealed extensive akinetic and diskinetic areas, significant stenosis being detectable either in the proximal area of the Ramus descendens anterior or in two or three blood vessels.