Intra-Aortic Balloon Counterpulsation

doi:10.1016/j.amjcard.2005.11.070

The American Journal of Cardiology

Volume 97, Issue 9, 1 May 2006, Pages 1391-1398

https://doi.org/10.1016/j.amjcard.2005.11.070 Get rights and content

Intra-aortic balloon counterpulsation (IABP) is sometimes used in critically ill patients with cardiac disease. By increasing diastolic arterial pressure and decreasing systolic pressure, it reduces left ventricular afterload. IABP may be beneficial in subjects with cardiogenic shock, mechanical complications of myocardial infarction, intractable ventricular arrhythmias, or advanced heart failure or those who undergo “high-risk” surgical or percutaneous revascularization, but the evidence to support its use in these patient groups is largely observational. Contraindications to IABP include severe peripheral vascular disease as well as aortic regurgitation, dissection, or aneurysm. The potential benefits of IABP must be weighed against its possible complications (bleeding, systemic thromboembolism, limb ischemia, and, rarely, death).

Section snippets

History

The beneficial effects of IABP are based on the principle of “counterpulsation,” whereby blood is pumped or displaced “out of phase” with the normal cardiac cycle (i.e., during left ventricular [LV] diastole). The application of this principle was first described (in experimental animals) by Adrian and Arthur Kantrowitz² in 1952. In 1958, Harken proposed an extracorporeal pump that would remove blood during LV systole, then return it during diastole, and in 1962, he and his colleagues described

Device Insertion and Operation

The IABP device is composed of (1) a double-lumen 8Fr to 9.5Fr catheter with a 25- to 50-ml balloon at its distal end and (2) a console with a pump to deliver gas to the balloon. Before insertion, an appropriate balloon size is selected (on the basis of the patient’s height). (Balloon recommendations from Datascope Corporation, Montvale, New Jersey, are as follows: for patients <5 ft [152 cm] tall, 25 ml; for those 5 ft to 5 ft 4 in [152 to 163 cm] tall, 34 ml; for those 5 ft 4 in to 5 ft 6 in

Concomitant Medications

Intravenous unfractionated heparin sufficient in amount to prolong an activated partial thromboplastin time to 50 to 70 seconds is considered to be standard therapy during IABP. Although heparin may prevent catheter-related thrombotic events, no data exist to support this belief. In fact, 1 study that randomly assigned 153 patients to receive heparin (or no heparin) during IABP found no difference in the incidence of limb ischemia.¹⁴

A nonfunctioning balloon should be removed promptly, or

Hematologic Effects

With IABP, hemoglobin and hematocrit often decrease modestly because of hemolysis from mechanical damage to erythrocytes as well as bleeding at the vascular access site. In 1 nonrandomized analysis of patients with myocardial infarctions (MIs), the 37 subjects in whom IABP was used had average decreases in hemoglobin and hematocrit of 2.3 g/dl and 5.7%, respectively, whereas the 13 patients without IABP device placement manifested decreases of 1.5 g/dl and 3.9%, respectively (p <0.05).¹⁷

Effects on systemic arterial pressure and LV performance

By increasing diastolic arterial pressure and decreasing systolic pressure, IABP reduces LV afterload. The magnitude of these effects varies among subjects and is dependent on (1) balloon volume, (2) heart rate, and (3) aortic compliance. The balloon volume is proportional to the volume of blood displaced: as balloon volume increases, the displaced blood volume increases commensurately. As heart rate increases, LV and aortic diastolic filling times decrease, producing less balloon augmentation

Cardiogenic shock

Registry data suggest that cardiogenic shock is 1 of the most common conditions for which IABP is used, accounting for about 20% of all insertions in the United States.35, 36 In 15 subjects with cardiogenic shock, Weiss et al³⁷ showed that IABP was associated with (1) decreases in LV end-diastolic and end-systolic volumes and pulmonary arterial wedge pressure and (2) increases in cardiac output, stroke volume, and the LV ejection fraction. Unfortunately, although hemodynamic and clinical

Contraindications to Intra-Aortic Balloon Counterpulsation

IABP is contraindicated in patients with aortic regurgitation because it worsens the magnitude of regurgitation. IABP device insertion should not be attempted in a patient with suspected or known aortic dissection, because inadvertent balloon placement in the false lumen may result in extension of the dissection or even aortic rupture. Similarly, aortic rupture is a potential consequence of IABP device insertion in patients with sizable abdominal aortic aneurysms.

Percutaneous IABP device

Complications of Intra-Aortic Balloon Counterpulsation

IABP may be associated with vascular complications, including bleeding, systemic embolization, limb ischemia, and amputation. In addition, as with any indwelling catheter, IABP may result in infection. We believe that the presence of a fever in a patient who undergoes IABP, in the absence of another clear source, requires balloon removal. IABP may be accompanied by mechanical complications, including balloon rupture, inadequate inflation, and inadequate diastolic augmentation. Rarely does a

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Association between red blood cell distribution width and all-cause mortality of patients after intra-aortic balloon pump in the intensive care unit
2024, Heliyon
This study aimed to explore the relationship between red blood cell distribution width (RDW) and all-cause mortality in critically ill patients undergoing intra-aortic balloon pumping (IABP) in the intensive care unit (ICU).
This study retrospectively analyzed data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The primary endpoint was the 30-day mortality rate, while the secondary endpoint was the in-hospital mortality rate. Restricted cubic splines were used to assess the dose–response relationship. The receiver operating characteristic (ROC) curve and Kaplan-Meier curve analysis were carried out to evaluate the predictive performance of RDW. Moreover, multiple logistic regression analyses and subgroup analyses were conducted to investigate the relationship between RDW and 30-day mortality. Finally, propensity score matching (PSM) was performed to adjust for the imbalance of covariates.
In total, 732 patients were finally identified from the MIMIC-IV database in this study. The RDW of patients in the non-survivor group was significantly higher compared with those in the survivor group (P < 0.01). Multiple logistic regression analyses corroborated RDW was an independent predictor of all-cause 30-day mortality in critically ill patients post-IABP. Meanwhile, ROC analysis identified an RDW cutoff of 14.2%. High RDW patients exhibited a 131% (OR = 2.31, 95% CI: 1.49–3.61) elevated risk of 30-day mortality after adjusting for confounders in multivariable logistic regression. After PSM, 412 patients were included in the matched cohort. In the original and matched cohorts, the high RDW group had higher 30-day and in-hospital mortality rates, as well as longer ICU stays. Lastly, the area under the ROC curve for 30-day mortality was 0.686, with an optimal cutoff point of 14.2 for RDW (sensitivity: 69.09 % and specificity: 63.32%).
RDW could be a simple and valuable prognostic tool to predict mortality in critically ill patients after IABP.
Mortality risk factors in patients receiving ECPR after cardiac arrest: Development and validation of a clinical prognostic prediction model
2024, American Journal of Emergency Medicine
Previous studies have shown an increasing trend of extracorporeal cardiopulmonary resuscitation (ECPR) use in patients with cardiac arrest (CA). Although ECPR have been found to reduce mortality in patients with CA compared with conventional cardiopulmonary resuscitation (CCPR), the mortality remains high. This study was designed to identify the potential mortality risk factors for ECPR patients for further optimization of patient management and treatment selection.
We conducted a prospective, multicentre study collecting 990 CA patients undergoing ECPR in 61 hospitals in China from January 2017 to May 2022 in CSECLS registry database. A clinical prediction model was developed using cox regression and validated with external data.
The data of 351 patients meeting the inclusion criteria before October 2021 was used to develop a prediction model and that of 68 patients after October 2021 for validation. Of the 351 patients with CA treated with ECPR, 227 (64.8%) patients died before hospital discharge. Multivariate analysis suggested that a medical history of cerebrovascular diseases, pulseless electrical activity (PEA)/asystole and higher Lactate (Lac) were risk factors for mortality while aged 45–60, higher pH and intra-aortic balloon pump (IABP) during ECPR have protective effects. Internal validation by bootstrap resampling was subsequently used to evaluate the stability of the model, showing moderate discrimination, especially in the early stage following ECPR, with a C statistic of 0.70 and adequate calibration with GOF chi-square = 10.4 (p = 0.50) for the entire cohort. Fair discrimination with c statistic of 0.65 and good calibration (GOF chi-square = 6.1, p = 0.809) in the external validation cohort demonstrating the model's ability to predict in-hospital death across a wide range of probabilities.
Risk factors have been identified among ECPR patients including a history of cerebrovascular diseases, higher Lac and presence of PEA or asystole. While factor such as age 45–60, higher pH and use of IABP have been found protective against in-hospital mortality. These factors can be used for risk prediction, thereby improving the management and treatment selection of patients for this resource-intensive therapy.
Evaluating the Use of Unfractionated Heparin with Intra-Aortic Balloon Counterpulsation
2024, Heart Lung and Circulation
Evidence supporting anticoagulation with unfractionated heparin (UFH) in patients with an intra-aortic balloon pump (IABP) to prevent limb ischaemia remains limited, while bleeding risks remain high. Monitoring heparin in this setting with anti-factor Xa (anti-Xa) is not previously described.
The study objective is to describe the incidence of thromboembolic and bleeding events with the use of UFH in patients with an IABP utilising monitoring with both anti-Xa and activated partial thromboplastin time (aPTT).
This is a retrospective study of adults who received an IABP and UFH for ≥24 hours. Electronic medical records were reviewed for pertinent data. The primary outcome was the incidence of limb ischaemia during IABP. Secondary outcomes included myocardial infarction, thrombus on IABP, or stroke. Exploratory outcomes included any venous thromboembolism and bleeding events.
Of 159 patients, 88% received an IABP for cardiogenic shock and median duration of IABP support was 118 hours (interquartile range, 67–196). Limb ischaemia occurred in four of 159 patients (2.5%). Strokes occurred in 3.8% of the cohort, and bleeding events occurred in 33%. Despite anticoagulation use in all patients, 11% experienced a venous thromboembolism, with most identified upon asymptomatic screening with concern for heparin-induced thrombocytopenia. We found no differences in outcomes that occurred with a hybrid anti-Xa and aPTT versus aPTT monitoring alone.
We observed a high rate of thrombotic and bleeding complications with the use of UFH in patients with an IABP. Use of anti-Xa versus aPTT for monitoring was not associated with complications. These data suggest safer anticoagulation strategies are needed in this setting.
Trends in Intra-Aortic Balloon Pump Use in Cardiogenic Shock After the SHOCK-II Trial
2023, American Journal of Cardiology
Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularization. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the IABP-SHOCK-II (Intra-aortic Balloon Pump in Cardiogenic Shock-II study) trial found no survival benefit. We aimed to determine the trends in IABP use in patients who underwent percutaneous intervention over time. Data were taken from patients in the Melbourne Interventional Group registry (2005 to 2018) with MI-CS who underwent percutaneous intervention. The primary outcome was the trend in IABP use over time. The secondary outcomes included 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCEs). Of the 1,110 patients with MI-CS, IABP was used in 478 patients (43%). IABP was used more in patients with left main/left anterior descending culprit lesions (62% vs 46%), lower ejection fraction (<35%; 18% vs 11%), and preprocedural inotrope use (81% vs 73%, all p <0.05). IABP use was associated with higher bleeding (18% vs 13%) and 30-day MACCE (58% vs 51%, both p <0.05). The rate of MI-CS per year increased over time; however, after 2012, there was a decrease in IABP use (p <0.001). IABP use was a predictor of 30-day MACCE (odds ratio 1.6, 95% confidence interval 1.18 to 2.29, p = 0.003). However, IABP was not associated with in-hospital, 30-day, or long-term mortality (45% vs 47%, p = 0.44; 46% vs 50%, p = 0.25; 60% vs 62%, p = 0.39). In conclusion, IABP was not associated with reduced short- or long-term mortality and was associated with increased short-term adverse events. IABP use is decreasing but is predominately used in sicker patients with greater myocardium at risk.
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ReviewIntra-Aortic Balloon Counterpulsation

Section snippets

History

Device Insertion and Operation

Concomitant Medications

Hematologic Effects

Effects on systemic arterial pressure and LV performance

Cardiogenic shock

Contraindications to Intra-Aortic Balloon Counterpulsation

Complications of Intra-Aortic Balloon Counterpulsation

J Thorac Cardiovasc Surg

Am Heart J

Am J Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Am J Cardiol

Am J Cardiol

Ann Thorac Surg

Am J Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Thorac Cardiovasc Surg

Am J Cardiol

Am J Med

Int J Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Review
Intra-Aortic Balloon Counterpulsation