Mechanical Support in Early Cardiogenic Shock: What Is the Role of Intra-aortic Balloon Counterpulsation?
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CARDIOGENIC SHOCK: PROGRESS IN MECHANICAL CIRCULATORY SUPPORT (JE RAME, SECTION EDITOR)
Mechanical Support in Early Cardiogenic Shock: What Is the Role of Intra-aortic Balloon Counterpulsation? Jesse R. Kimman 1 & Nicolas M. Van Mieghem 1 & Henrik Endeman 2 & Jasper J. Brugts 1 & Alina A. Constantinescu 1 & Olivier C. Manintveld 1 & Eric A. Dubois 1,2 & Corstiaan A. den Uil 1,2
# The Author(s) 2020
Abstract Purpose of Review We aim to summarize recent insights and provide an up-to-date overview on the role of intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS). Recent Findings In the largest randomized controlled trial (RCT) of patients with CS after acute myocardial infarction (AMICS), IABP did not lower mortality. However, recent data suggest a role for IABP in patients who have persistent ischemia after revascularization. Moreover, in the growing population of CS not caused by acute coronary syndrome (ACS), multiple retrospective studies and one small RCT report on significant hemodynamic improvement following (early) initiation of IABP support, which allowed bridging of most patients to recovery or definitive therapies like heart transplant or a left ventricular assist device (LVAD). Summary Routine use of IABP in patients with AMICS is not recommended, but many patients with CS either from ischemic or non-ischemic cause may benefit from IABP at least for hemodynamic improvement in the short term. There is a need for a larger RCT regarding the role of IABP in selected patients with ACS, as well as in patients with non-ACS CS. Keywords Intra-aortic balloon counterpulsation . Mechanical circulatory support . Cardiogenic shock . Heart failure
Key Points • The routine use of IABP in patients with AMICS after successful PCI was not shown to be beneficial or harmful compared with optimal medical therapy, regardless of the timing of placement. However, in the subgroup of patients with impaired coronary autoregulation due to unsuccessful primary PCI, IABP might still be helpful. • Although pVADs like Impella may be more appropriate to use in highrisk PCI, the use of pVADs has so far demonstrated equal or higher mortality compared with IABP in patients with AMICS. • Main trials have focused on AMICS, and therefore, there is a need for (larger) RCTs regarding the use of IABP in non-ACS CS and advanced HF, which concerns over 50% of patients with CS in recent studies. • Studies that reflect clinical experience or pilot experiments of IABP in non-ACS CS show good hemodynamic improvement which allowed stabilization and clinical decision-making. A high percentage of these patients can be bridged to recovery or may receive destination therapy with good long-term outcome. This article is part of the Topical Collection on Cardiogenic Shock: Progress in Mechanical Circulatory Support * Jesse R. Kimman [email protected]
1
Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
2
Department of Intensive Care Medicin
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