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Advanced Angioplasty 2003
Non-Coronary Intervention
Circulatory Support
Andreas Baumbach
Bristol Royal Infirmary
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Circulatory Support
PCI / Acute MI
Cardiogenic shock
Cardiac Surgery
High risk CABG
Weaning
Bridge to transplant
Chronic Heart Failure ?
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Circulatory Support
Balloon Counterpulsation
Results & Evidence
Guidelines
Assist Devices: Developments
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Intra-Aortic Balloon Pump
• Inflatable 32-40 cc
balloon
• Triggered to inflate with
helium immediately after
aortic valve closure
• Triggered to deflate with
opening of the aortic
valve
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Intra-Aortic Balloon Pump
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Intra-Aortic Balloon Pump
Decreases Afterload
Increases Diastolic Aortic Pressure
Increases Coronary Flow Velocity
Reduces Myocardial Oxygen Demand
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Circulatory Support
Balloon Counterpulsation
Results & Evidence
Guidelines
Assist Devices: Developments
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Intra-Aortic Balloon Pump
Current Practice
Results from the Benchmark Registry
Ferguson et al. J Am Coll Cardiol 2001; 38:1456
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Benchmark Registry
• June 96-August 2000
• 203 Hospitals (90%US)
• 16909 patient case records
• Verified by external audit
Ferguson et al. J Am Coll Cardiol 2001; 38:1456
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Benchmark Registry:
Indication
• Hemodynamic support during/after
catheterisation
• Cardiogenic shock
• Weaning from CP bypass
• Preoperative use in high risk pts
• Refractory unstable angina
20.6%
18.8%
16.1%
13%
12.3%
Ferguson et al. J Am Coll Cardiol 2001; 38:1456
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Benchmark Registry: Complications
• Major: Limb ischemia, severe bleeding,
balloon leak, death due to IABP
2.6%
• In –hospital mortality
21.2%
• Failed IABP insertion
2.3%
• Increased risk for major complications:
–
–
–
–
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Women
Low BSA
Older patients
PVD
Ferguson et al. J Am Coll Cardiol 2001; 38:1456
IABP Evidence
A prospective randomized evaluation of
prophylactic intraaortic balloon
counterpulsation in high risk patients with
acute MI treated with primary angioplasty
Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty
Hypothesis: routine use of IABP after primary
PCI reduces infarct related artery reocclusion
Multicentre, randomised trial
High risk patients randomised to 36 to 48hrs
IABP or standard care
Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty
*Stents 1.3%
High risk
Age>70yrs
3 vessel disease
LVEF<45%
SVG occlusion
Persistent malignant arrhythmia
Subotpimal result*
Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty
N:1100 Angio for MI
N: 908 randomised
N: 437 high risk
IABP 211
Established 86%
no IABP 226
Crossover 13%
Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty
28.9 29.2
30
25
20
23
IABP
no IABP
19.9
15
8
10
5
4.3 3.1
6.2
6.7 5.5
2.4
0
0
Death
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Re-MI
Reoccl
Stroke
CHF
Hypo
Endpoint
Stone et al. J Am Coll Cardiol 1997
IABP in direct angioplasty
Complications
No difference in hemorrhagic complications or vascular
complications
Significant difference in stroke
‘This finding may be due to chance
….. One intracranial hemorrhage developed after a
postinfarction patient was hit in the head with a shovel while
robbing the hospital nursery ‘
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Stone et al. J Am Coll Cardiol 1997
IABP Evidence
A randomized comparison of intraaortic
balloon pumping after primary coronary
angioplasty in high risk patients with
acute MI treated
Van ‘t Hoft 1999, Eur Heart J
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IABP Evidence
N 238 over 3.5 years
118 IABP
120 no IABP
Primary endpoint: Death, Re-MI, stroke, EF<30% at 6
months FU
-> 26% vs 26%
No difference in EF
8% major complications in IABP group
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Van ‘t Hoft 1999, Eur Heart J
IABP Evidence: SHOCK
Impact of thrombolysis, intra-aortic balloon
pump counterpulsation, and their combination
in cardiogenic shock complicating acute
myocardial infarction
A report from the SHOCK trial registry
Sanborn et al. J Am Coll Cardiol 2000;
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IABP Evidence: SHOCK
Background:
National registry of MI suggests lower mortality in pts
treated with thrombolysis followed by IABP (49%)
compared with thrombolysis alone (69%)
GUSTO trend towards better outcome
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Sanborn et al. J Am Coll Cardiol 2000; 36:1123
SHOCK Registry
N: 856 patients with cardiogenic shock in acute MI
36 participating centres
Treatment:
• No thrombolysis / no IABP
• IABP only
• Thrombolysis only
• Thrombolysis and IABP
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33%
33%
15%
19%
Sanborn et al. J Am Coll Cardiol 2000; 36:1123
SHOCK Registry: Mortality
Cardiogenic shock
(LV Failure)
No thrombolysis
n=564
64%
No IABP
n=285
77%
no revasc
n=233
83%
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revasc
n=52
48%
Thrombolysis
n=292
54%
IABP
n=279
52%
no revasc
n=84
76%
No IABP
n=132
63%
revasc
n=195
41%
no revasc
n=105
74%
revasc
n=27
19%
p=.005
IABP
n=160 p<.0001
47%
no revasc
n=51
69%
revasc
n=109
37%
Sanborn et al. J Am Coll Cardiol 2000; 36:1123
SHOCK Result
IABP vs. no IABP mortality after adjustement for
revascularisation p=0.313
Use of IABP with or without thrombolysis improves
survival in pts with cardiogenic shock because of the
higher rate of attempted revascularisation in the IABP
group
Sanborn et al. J Am Coll Cardiol 2000; 36:1123
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Circulatory Support
Balloon Counterpulsation
Results & Evidence
Guidelines
Assist Devices: Developments
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Guidelines
“Emergency high risk PCI such as direct PCI for acute MI can
usually be performed without IABP or CPS.
…
However, it should be noted that in patients with borderline
hemodynamics, ongoing ischemia, or cardiogenic shock,
insertion of an intra-aortic balloon just prior to coronary
instrumentation has been associated with improved outcomes.
Furthermore it is reasonable to obtain vascular access in the
contralateral femoral artery prior to the procedure in patients
in whom the risk of hemodynamic compromise is high…”
AHA/ACC Guidelines for PCI, Circulation 2001
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Guidelines
Recommendations for the use of IABP in the treatment of AMI
Class I
•Cardiogenic shock not quickly reversed with pharmacological
therapy as a stabilising measure for angiography and prompt
revascularisation
•Acute MR or VSD – as a stabilising therapy for angio and repair/
revascularisation
•Recurrent intractable ventricular arrhythmias with hemodynamic
instability
•Refractory post –MI angina as a bridge to revascularisation
AHA/ACC Guidelines for AMI, JACC 1996, Web update 1999
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Guidelines
Recommendations for the use of IABP in the treatment of AMI
Class IIa
Signs of hemodynamic instability, poor LV , or persistent
ischemia in patients with large areas of myocardium at risk
Class IIb
Following successful angioplasty to prevent reocclusion
Large areas at risk w/o active ischemia
AHA/ACC Guidelines for AMI, JACC 1996
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Summary IABP
Intra-Aortic Balloon Pump is an excellent
tool for the management of
hemodynamically unstable patients
especially in the setting of acute MI
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Circulatory Support
Balloon Counterpulsation
Results & Evidence
Guidelines
Assist Devices: Developments
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Assist Devices: Indications
•
•
•
•
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Cardiogenic shock in AMI
Postsurgical myocardial dysfunction
Acute cardiac failure from myocarditis
Decompensated chronic heart failure
Assist Devices: Goals
• Bridge to transplantation
• Bridge to recovery
• Alternative to heart transplantation
Delgado et al Circulation 2002;106:2046
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Devices
• Extracorporeal Assist (e.g.Thoratec/Abiomed)
• Implantable LV assist devices (Heartmate)
• Axial Flow pumps
• Totally implantable LVAD (Lion Heart)
• Total Artificial Heart
(ABIOCOR)
Delgado et al Circulation 2002;106:2046
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HeartmateTM
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Heartmate
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Heartmate
N:129
Quality of life
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AbiocorTM
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AbiocorTM
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AbiocorTM
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AbiocorTM
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Assist Devices
Progress in technology promises new surgical
treatment options for end stage heart failure
Our surgical colleagues should be pleased to
finally have hearts that we won’t fix with
percutaneous intervention
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