Intra-Aortic Counterpulsation in Heart Failure
Intra-Aortic Counterpulsation in Heart Failure
Background. Intra-aortic counterpulsation (IABP) is frequently applied to provide hemodynamic support in patients with refractory cardiogenic shock (CS) of ischemic and non-ischemic cause. However, clinical data comparing outcomes are lacking for both indications. The purpose of this analysis was to evaluate outcome and safety of IABP support in patients with ischemic and non-ischemic CS and to identify predictors of early mortality in this severely ill patient population.
Methods and Results. For the period between 1998 to 2010, data from 489 consecutive patients (age, 67.2 ± 12.2 years; 65.9% male) who had received IABP support for CS at the University Heart Center Jena were retrospectively analyzed. The primary endpoint was overall mortality at 7 and 30 days. Secondary endpoints included the incidence of vascular and neurologic complications as well as long-term survival. Follow-up data on current health status of the patients were acquired either from health insurance records or based on patient and physician interviews. After data compilation, patients were assigned to one of the following subgroups: ST-elevation myocardial infarction (STEMI; n = 368; 75.3%), non-STEMI (n = 75; 15.3%) and congestive heart failure (CHF; n = 46; 9.4%). Of the 489 patients enrolled, 422 (86.4%) were successfully weaned from IABP support. However, a significantly lower proportion of patients were weaned successfully in the STEMI group (n = 310; 84.1%) compared to the other two groups (non-STEMI: n = 70, 92.4%; CHF: n = 45, 97.8%; P=.041). Overall mortality at 30 days was 36.4% (n = 178) and was not significantly different between the subgroups. Significant predictors of 30-day mortality included age >70 years (odds ratio [OR], 16.81; confidence interval [CI], 1.241–227.54), ejection fraction <40% (OR, 36.33; CI, 2.93–451.05) and mechanical ventilation (OR, 12.42; CI, 1.21–127.17). Long-term follow-up was 803 ± 1061 days (range, 0–1380 days), with a long-term survival rate of 38.3%.
Conclusion. IABP represents a safe technology for hemodynamic support and is associated with low complication rates. Parameters relating to early mortality include age >70 years, respiratory failure requiring mechanical ventilation, and left ventricular function <40%, which represent an additional risk of death. However, the etiology of CS had no effect on mortality in this analysis. This observation should encourage physicians to apply IABP for hemodynamic support in patients with non-ischemic left ventricular failure.
Intra-aortic counterpulsation (IABP) is a widely used concept of circulatory support in patients with cardiogenic shock (CS). Introduced in 1962 to augment native cardiac function by afterload reduction and improvement of coronary perfusion, the method was applied clinically for the first time by Kantrowitz et al in 1968. Since then, IABP therapy has improved considerably and has evolved into a mature technique with more than 160,000 applications each year worldwide. Mechanical support using IABP in CS complicating acute myocardial infarction has a Class I guideline recommendation. However, it is also applied to provide hemodynamic support in CS for other, potentially irreversible causes of left ventricular (LV) dysfunction, such as refractory congestive heart failure. Despite the frequent use of IABP support for a wide range of serious cardiovascular conditions, in the literature, there are few data comparing the outcome of IABP support in CS between potentially reversible versus irreversible causes. Therefore, the purpose of this registry was to review our institutional experience with IABP-application in patients with CS from ST-elevation myocardial infarction (STEMI), non-STEMI, and refractory chronic heart failure (CHF) in order to assess safety and outcome, as well as to identify predictors of early mortality.
Abstract and Introduction
Abstract
Background. Intra-aortic counterpulsation (IABP) is frequently applied to provide hemodynamic support in patients with refractory cardiogenic shock (CS) of ischemic and non-ischemic cause. However, clinical data comparing outcomes are lacking for both indications. The purpose of this analysis was to evaluate outcome and safety of IABP support in patients with ischemic and non-ischemic CS and to identify predictors of early mortality in this severely ill patient population.
Methods and Results. For the period between 1998 to 2010, data from 489 consecutive patients (age, 67.2 ± 12.2 years; 65.9% male) who had received IABP support for CS at the University Heart Center Jena were retrospectively analyzed. The primary endpoint was overall mortality at 7 and 30 days. Secondary endpoints included the incidence of vascular and neurologic complications as well as long-term survival. Follow-up data on current health status of the patients were acquired either from health insurance records or based on patient and physician interviews. After data compilation, patients were assigned to one of the following subgroups: ST-elevation myocardial infarction (STEMI; n = 368; 75.3%), non-STEMI (n = 75; 15.3%) and congestive heart failure (CHF; n = 46; 9.4%). Of the 489 patients enrolled, 422 (86.4%) were successfully weaned from IABP support. However, a significantly lower proportion of patients were weaned successfully in the STEMI group (n = 310; 84.1%) compared to the other two groups (non-STEMI: n = 70, 92.4%; CHF: n = 45, 97.8%; P=.041). Overall mortality at 30 days was 36.4% (n = 178) and was not significantly different between the subgroups. Significant predictors of 30-day mortality included age >70 years (odds ratio [OR], 16.81; confidence interval [CI], 1.241–227.54), ejection fraction <40% (OR, 36.33; CI, 2.93–451.05) and mechanical ventilation (OR, 12.42; CI, 1.21–127.17). Long-term follow-up was 803 ± 1061 days (range, 0–1380 days), with a long-term survival rate of 38.3%.
Conclusion. IABP represents a safe technology for hemodynamic support and is associated with low complication rates. Parameters relating to early mortality include age >70 years, respiratory failure requiring mechanical ventilation, and left ventricular function <40%, which represent an additional risk of death. However, the etiology of CS had no effect on mortality in this analysis. This observation should encourage physicians to apply IABP for hemodynamic support in patients with non-ischemic left ventricular failure.
Introduction
Intra-aortic counterpulsation (IABP) is a widely used concept of circulatory support in patients with cardiogenic shock (CS). Introduced in 1962 to augment native cardiac function by afterload reduction and improvement of coronary perfusion, the method was applied clinically for the first time by Kantrowitz et al in 1968. Since then, IABP therapy has improved considerably and has evolved into a mature technique with more than 160,000 applications each year worldwide. Mechanical support using IABP in CS complicating acute myocardial infarction has a Class I guideline recommendation. However, it is also applied to provide hemodynamic support in CS for other, potentially irreversible causes of left ventricular (LV) dysfunction, such as refractory congestive heart failure. Despite the frequent use of IABP support for a wide range of serious cardiovascular conditions, in the literature, there are few data comparing the outcome of IABP support in CS between potentially reversible versus irreversible causes. Therefore, the purpose of this registry was to review our institutional experience with IABP-application in patients with CS from ST-elevation myocardial infarction (STEMI), non-STEMI, and refractory chronic heart failure (CHF) in order to assess safety and outcome, as well as to identify predictors of early mortality.
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