Transcript Intra-Aortic Balloon Pumps: A Review for Cardiologists

Intra-Aortic Balloon Pumps: A Review for
Cardiologists
Quinn Capers, IV, MD, FACC, FSCAI
Division of Cardiovascular Medicine
The Ohio State University Medical
Center
IABP: Definition
 40 cc volume, cylindrical balloon
 Advanced from femoral artery into aorta
 Usually percutaneously (Seldinger technique), with a
sheath (6.5-10.5)
IABP: Definition
 Attached via gas and arterial pressure tubing to
portable control module
 Inflated with inert gas immediately at aortic valve
closure
 Actively deflated immediately prior to systole
IABP inflates with aortic valve closure:
Provides pressurized pulse of blood against
closed aortic valve, increasing coronary perfusion
IABP deflates immediately prior to aortic valve opening:
Reduces LV afterload
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IABP: Physiology
 Inflation at aortic valve closure:
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Increases aortic diastolic blood pressure
Increases diastolic coronary perfusion
Net neutral effect on cerebral perfusion
Increases C.O./“runoff” to subdiaphragmatic organs
 Deflation prior to systole:
 Reduces impedance to LV ejection (afterload)
 Reduces myocardial oxygen consumption
IABP: Physiology
 2 main beneficial effects:
 1) Augmented coronary perfusion
 2) Reduced LV afterload/Increased CO
IABP: Physiology
 2 main beneficial effects:
 1) Augmented coronary perfusion
 Only in normal coronary arteries
 No augmentation beyond severe stenoses pre PCI
 Augmentation beyond severe stenoses post PCI
 2) Reduced LV afterload/Increased CO
IABP: Physiology
 2 main beneficial effects:
 1) Augmented coronary perfusion
 2) Reduced LV afterload/Increased CO
 Most important of 2 main effects when severe coronary
stenoses present
IABP: Indications
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Cardiogenic shock
Unstable AMI pt
Prior to hi risk PCI
Prior to hi risk CABG
Refractory CHF
Refractory VT/VF
Severe MR
Refractory angina
 “Rescue” after failed
PCI going to CABG
 Bridge to heart txp
IABP: Contraindications
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 Absolute
 Relative
 Known severe aortic
pathology (dissxn,
ulcer, mobile plaques)
 Significant AI
 Patient refusal
 Severe PVD
 AAA
 Mild AI
IABP: Current Practice
 Ferguson. JACC 2001.
 Registry, 6/96-8/00: 16, 909 pts in 203 ctrs
 Indications:
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20.6%
18.8%
16.1%
13%
12.3%
high risk cath/PCI
cardiogenic shock
weaning from CPB
preop CABG, high risk or unstable pt
refractory USA
IABP: Complications
 Ferguson. JACC 2001.
 Benchmark Registry. 16, 909 pts, 203 ctrs
 Complications:
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2.9% Limb ischemia
2.4% Access site bleeding
1% Balloon leak
0.05% Death attributable to IABP
IABP: Complications
Risk Factors
 Odds Ratios for Major complications with IABP
therapy:
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PVD: 2.0
Female Gender: 1.7
Small BSA: 1.5
Advanced age: 1.3
(Little Old Ladies!!!)
IABP Insertion: Methods
 Choose groin with strongest pulse
 Consider iliac angiogram
 Document pedal pulses before IABP inserted
IABP Insertion: Methods
 Note that sheath is not mandatory
 Advantage: IABP passage may be less traumatic
 Disadvantage: Bigger hole, ? more limb ischemia
IABP Insertion: Methods
 Advance IABP over wire under fluoro
 Distal (cephalad) marker placed at carina
(Caudad to L SC artery)
 Aspirate blood from lumen of IABP
 Hook up “bubble free” to fluid filled pressure tubing
IABP Insertion: Methods
 Connect gas line and fill IABP
 Begin pumping 1:2 under fluoro
 Ensure full expansion, no kinking, IABP not in iliac
artery
 Examine pressure wave forms
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IABP: Essential Questions
 Anecdotally, we think it is a beneficial in cardiogenic
shock and high risk coronary revascularization.
1.
Do we have randomized data that it is beneficial in high risk PCI?
2.
If IABP is beneficial in high risk PCI, does the timing of IABP
placement matter? (i.e., prior to PCI, during PCI after complications
arise, after PCI?)
3.
Is anticoagulation necessary when IABPs are in place?
IABP: To Anticoagulate or Not?
 J Zheijiang Univ Sci 2003 Sep-Oct; 4 (5): 607-611
 153 pts with IABP x 48 hrs randomized to IV heparin
or placebo
 No difference in limb ischemia, clot on balloon surface
upon removal
 Increased major and minor bleeding in heparin group
Acute Card Care. 2008
The role of heparin anticoagulation during intra-aortic balloon
counterpulsation in the coronary care unit.
Cooper HA1, Thompson E, Panza JA
.
 Universal Heparin (n=102) vs Strategic Heparin (n=150) in IABP pts
 100% of UH pts and 47% of SH pts received Heparin
 Major bleeding 10.8% vs 3.2% (p<0.05) in Universal vs Strategic
group
 Bleeding was non-access site related
J Card Surg. 2012 Heparin-free management of intra-aortic balloon
pump after cardiac surgery.
Kogan A1, Preisman S, Sternik L, Orlov B, Spiegelstein D, Hod H,
Malachy A, Levin S, Raanani E.
 203 pts requiring IABP post-CABG
 None treated with Heparin
 IABP duration: < 24 hr in 81 pts, > 24 hrs in 122 pts
 No major bleeding complications in any pts
IABP: To Anticoagulate or Not?
 No recommendations by manufacturers
 Generally not thought to be necessary if pumping
1:1
 Reasonable if during a long wean while pumping 1:2
or 1:3
IABP in High-Risk PCI
Is it Useful?
 IABP placed for PCI
 Brodie AJC 1999
 Cardiac arrest decreased by 52%
 O’Murchu JACC 1995
 Decrease MI in rotational atherectomy
 Ohman Circ 1994
 Decreased reocclusion of IRA in MI pts
 Decreased MACE
IABP in High-Risk PCI
 IABP placed after PCI
 Van’t Hof Eur Heart J 1999
 No benefit
 PAMI II JACC 1997
 No benefit
IABP in High-Risk PCI
 What if it’s placed before the high risk PCI?
IABP in High-Risk PCI
 Mishra AJC 2006
 300 high risk pts, 69 had IABP inserted
prophylactically
 Remaining pts had sheath inserted, leads on chest,
IABP in the room, “on standby”
 46 pts needed “rescue” IABP
IABP in High-Risk PCI
Prophylactic (69)
“Rescue” (46)
In hosp death: 0%
MI:
20%
30 day death: 4%
22%
62%
27%
Mishra AJC 2006
IABP in High-Risk PCI
 Briguori AHJ 2003
 133 pts with LVEF < or = 30%
 Prophylactic
 Shock: 0%
 MACE: 0%
“Rescue”
15%
17%
(MI, CABG, Death)
*Prophylactic pts had more high risk characteristics
IABP in High-Risk PCI
 Prophylactic strategy proven superior to
“standby” strategy in several studies:
 SHOCK trial (Death rate 57% vs 72%)1
 GUSTO (MACE rate 47% vs 60%)2
 NRMI (MACE rate 49% vs 67%)3
1Hochman
2Topol
3Circ
Circ 1995
JACC 1995
2003
IABP in High-Risk PCI?
 Briguori AHJ 2006
 219 pts with unprotected LM lesions
 Prophylactic (69)
 Shock: 0%
 MACE: 1.5%
“Rescue” (150)
8%
9.5%
*Prophylactic pts had more high risk characteristics
IABP in High-Risk PCI
 A strategy of prophylactic placement of IABP before
high risk PCI appears to be superior to a “rescue”
strategy
 If you think you need it, you probably do!
From: Elective Intra-aortic Balloon Counterpulsation During High-Risk Percutaneous Coronary Intervention: A
Randomized Controlled Trial
JAMA. 2010;304(8):867-874. doi:10.1001/jama.2010.1190
Figure Legend:
Mortality at 6 months was numerically lower in the elective intra-aortic balloon pump (IABP) group than in the no planned IABP
group, although this was not statistically significant (4.6% vs 7.4%, P = .32 by the χ2 test).
Date of download: 7/18/2013
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Copyright © 2012 American Medical
Association. All rights reserved.
N Engl J Med. 2012 Oct 4;367(14):1287-96. doi: 10.1056/NEJMoa1208410.
Epub 2012 Aug 26.
Intraaortic balloon support for myocardial infarction with cardiogenic
shock.
Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M,
Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm M, Ebelt H, Schneider S,
Schuler G, Werdan K; IABP-SHOCK II Trial Investigators.
 600 pts with STEMI complicating cardiogenic
shock
 Randomized to IABP vs no IABP
 Primary endpoint: Mortality
N Engl J Med. 2012 Oct 4;367(14):1287-96. doi: 10.1056/NEJMoa1208410. Epub 2012
Aug 26.
Intraaortic balloon support for myocardial infarction with cardiogenic shock.
Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G,
Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm
M, Ebelt H, Schneider S, Schuler G, Werdan K; IABP-SHOCK II Trial Investigators.
“In this large, randomized trial involving patients with cardiogenic shock complicating
acute myocardial infarction, for whom early revascularization was planned,
intraaortic balloon pump support did not reduce 30-day mortality.”
“there was no significant difference in mortality between the 37 patients (13.4%) in
whom the balloon pump was inserted before revascularization and the
240 patients (86.6%) in whom the balloon pump was inserted after revascularization”
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BCIS-1 long term follow up vs IABP-Shock II
(What’s the difference?)
“there was no significant difference in mortality between the 37 patients (13.4%) in
whom the balloon pump was inserted before revascularization and the 240 patients
(86.6%) in whom the balloon pump was inserted after revascularization”--IABP Shock II investigators
“In the group assigned to elective IABP treatment, the balloon catheter is inserted at the
start of the procedure, before coronary intervention.”—
BCIS trial investigators
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IABP: Important Questions:
 1) Do we have randomized data? Yes, but mostly anecdotal and registry
 2) Does it matter if they are placed prior to or after PCI? ?
 3) Is anticoagulation necessary?
No, if </= 48hrs
Impella
 Percutaneous LVAD
 14 Fr sheath
 Increases cardiac output (2.5 L/min) & unloads
LV
Blood Inlet
Blood outlet
Motor
Pressure Lumen
PROTECT II MACCE**
Per Protocol Population, N=426
Death, Stroke, MI,
Repeat revasc.
IABP
IMPELLA
Log rank test, p=0.04
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IABP: Post-Test
• Iliac artery atherosclerosis is an absolute
contraindication for placing an IABP. True or False?
• There is no evidence that systemic anticoagulation is
indicated in patients with an indwelling IABP. True or
False?
• The most common complication of IABPs is related to
balloon rupture/leak. True or False?
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IABP: Post-Test
• In patients with multiple, critical coronary stenoses and
refractory angina, IABPs are useful to decrease angina.
In such situations the main mechanism of benefit is:
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LV afterload reduction
Increased coronary perfusion
Increased peripheral arterial blood pressure
Increased peripheral arterial “runoff”
IABP: Post-Test
• You are about to perform a complex PCI in a patient with
severe LMCA disease and severe LV dysfunction? You
think you may need a balloon pump. How will you
proceed?
• Placing the IABP prior to PCI
• Placing the IABP after PCI
• Having the IABP “ready to go” (in the room, sheath
in groin, IABP EKG leads on pt) in case the patient
“crashes”
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IABP: Post-Test
• Based on currently available evidence, which of the
following pts would you predict to have the highest risk
for a complication of IABP placement?:
• A morbidly obese (350#) man with diabetes
• A 65 year old man with femoral bruits
• A 90 year old woman that weighs 90 # and suffers
from severe claudication
• A 70 year old man with a small (3.5 cm) AAA
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IABP: Post-Test
Analyze this aortic pressure waveform in a pt with an IABP in place.
What is the problem? How do you fix it?
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Conclusions
 IABPs are extremely useful in stabilizing pts with complicated
cardiac disease
 Risk factors for complications with IABPs are: female sex, PVD,
small BSA, age
 Troubleshooting with waveform analysis is critical, and is just as
important as knowing how to insert an IABP
Conclusions
 Prophylactic insertion of an IABP for hemodynamic support in high
risk PCI pts may be superior to a “rescue” strategy
 Controversy has arisen as to the utility of IABPs, but registry data,
randomized data, and anecdotal data can be quoted to support their
benefit.
 More studies needed, especially re: impact of timing of placement