The document discusses the use of primary intra-aortic balloon pumps (IABP) for cardiogenic shock. It provides evidence from several studies that early use of IABP before inotropes results in better outcomes for patients, including higher survival rates. For ischemic cardiogenic shock, IABP is thought to reduce oxygen demand on the heart and decrease left ventricular pressure. The document reviews multiple trials demonstrating the benefits of IABP, especially when used very early in cardiogenic shock. However, more large studies are still needed to fully understand the benefits of IABP.

1. Primary Intra-Aortic Balloon Pump (P IABP)
ANWER GHANI
FIBMS
IRAQ

2. Primary Intra-Aortic Balloon Pump (P IABP) means
the use of IABP before inotropes for cardiogenic
Shock (CS).

3. The overall haemodynamic effects of IABP therapy

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IABP IN CS
 The overall hospital survival of patients with reported CS
was 40.2%. (1)

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IABP IN CS
 Hospital survival rate of patients with (any) MCS is higher
than in patients without (survival: any MCS = 44.8%; medical
treatment = 39.5%). (1)

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IABP IN CS
 Survival of patients on MCS was significantly different
between the devices (survival: IABP = 49.5%; pVAD = 36.2%;
VA-ECMO = 30.5%. (1)
 (MCS) = mechanical circulatory support

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IABP IN CS
 Survival: IABP = 49.5%. (1)
It should be borne in mind that IABP patients are more risky than inotropes patients. However,
it achieves a higher rate of survival.

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IABP IN CS
 Highest overall survival was detected in patients with IABP in
comparison to other MCS. (1)

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IABP IN CS
 The hospital survival rates of patients with IABP were
significantly higher than for patients with other MCS or for
patients with medical therapy. (1)

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IABP IN NICS
NICS= Non ischemic CS
∆SvO2 was higher in the IABP group compared to intopes
(+17 vs. +5 ). (2)
(SvO2)= mixed-venous oxygen saturation to assess organ perfusion.

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IABP IN NICS
IABP patients had a higher ∆CPO in comparison to
Inotropes patients. (2)
(CPO) =cardiac power output

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IABP IN NICS
IABP patients had a a greater relative reduction in NT-proBNP
in comparison to Inotropes patients. (2)

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IABP IN NICS
IABP patients had a more negative cumulative fluid
balance in comparison to Inotropes patients. (2)

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IABP IN NICS
IABP patients had a greater reduction in dyspnoea
severity score. in comparison to Inotropes patients. (2)

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IABP IN NICS
There were no IABP-related serious adverse events (SAEs). (2)

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IABP IN NICS
Thirty-day mortality was 23% (IABP) vs. 44% (INO). (2)
THIS IS SO IMPORTANT

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IABP IN ICS
ICS = Ischemic CS
 The predominant benefit of IABP on high-risk patients with
severe coronary stenosis may relate to a reduction in oxygen
demand through LV systolic unloading over and above that
stimulated by diastolic augmentation of the coronary blood
flow. (3)

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IABP IN ICS
 By decreasing LV end-diastolic pressure following an
unloading of the LV, IABP decreases the LV wall tension and
LV transmural pressure. (3)

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IABP IN ICS
 Few studies are available concerning the use of IABP
compared to standard of care (noradrenalin, dobutamine, and
intensive care unit management) or Impella mechanical
support device.(3)

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IABP IN ICS

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IABP IN ICS
 Cardiogenic shock complicating myocardial infarction: in the
thrombolytic era, IABP was mainly implanted in patients with
haemodynamic instability or CS with overall favourable
results in registries or small randomized trials. (4)

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IABP IN ICS
 IABP wide use has been in part related to the Class I
recommendation set in the previous European and American
guidelines, despite a level of evidence of C and B
respectively due to the small sample size of the supporting
studies (mostly observational). (4)
 Today, IABP usage has a class IIb recommendation in the American guidelines and a class III recommendation in
the European guidelines according to IABP SHOCK II study and others.

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IABP IN ICS
 IABP-SHOCK II is currently the largest available randomized
clinical trial investigating the role of IABP in patients with
AMI and CS, and the authors should be commended for their
efforts. However, several study limitations are evident. (4)

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IABP IN ICS
 However, all the aforementioned studies were not adequately
powered either to investigate an association between IABP
and mortality as a single Endpoint or to draw definite
conclusions. (4)

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IABP IN ICS
 The neutral results of the IABP-SHOCK II trial might be
related to a late IABP implantation, which occurred in the
vast majority of cases after PCI. (4)
 Today, IABP usage has a class IIb recommendation in the American guidelines and a class III recommendation in
the European guidelines according this study and others.

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IABP IN ICS
 The insertion of IABP before PCI was associated with a
significant reduction in mortality and adverse cardiovascular
events. (4)

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IABP IN ICS
 Recently, a study including patients with CS due to different
aetiologies, confirmed that an early placement of IABP was
an independent predictor of 30 days survival. (4)

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IABP IN ICS
 In a subgroup analysis of the CRISP-AMI trial in patients with
large anterior STEMI and persisting ischaemia after PCI, the
use of IABP was associated with a significant mortality
reduction at 6 months. (4)

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IABP IN ICS
 In Hawranek et al. (7200 patients with AMI complicated by CS)
 Patients treated with IABP presented lower systolic arterial
pressure and LVEF, higher heart rate, rate of multivessel
coronary artery disease, and involvement of left main and left
anterior descending artery.
 The use of IABP was associated with higher 30-day and 1-
year mortality, recurrent MI, stroke, recurrent PCI, major
bleeding, and cardiac arrest, due to the higher risk profile of
patients treated with the device. However, in patients with
final TIMI flow 0/1, IABP use was an independent predictor of

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IABP IN ICS
 The use of IABP should be considered in the very early
phases of CS and in patients with impending shock. (4)

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IABP IN ICS
 Therefore, it is crucial to timely identify patients who are at
risk of developing CS (or in CS initial phase) searching for
early signs of CS such as initial increase in lactate levels in a
setting of organ hypoperfusion. (4)

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IABP IN ICS
 It seems reasonable to proceed with IABP implantation in
patients with impending shock/CS, provided it is implanted in
the very early phases of heart failure/CS. (4)

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Conclusions
 We need:
1- more and big studies about IABP.
2- more targets other than mortality.
2- Early IABP use.
 IABP looks more useful than we think.

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Reference
1-Corinna N. Lang et al; Cardiogenic shock: incidence, survival and mechanical circulatory support usage 2007–2017-insights from a national registry. Clin Res
Cardiol. 2021; 110(9): 1421–1430.
2- Corstiaan A den Uil 1et al; Primary intra-aortic balloon support versus inotropes for decompensated heart failure and low output: a randomised trial.-
EuroIntervention 2019 Sep 20;15(7):586-593.
3-Florian Rey et al; Intra-Aortic Balloon Pump and Ischemic Cardiogenic Shock May Still Be a Valuable Association. J Clin Med. 2021 Feb; 10(4): 778.
4- Roberta Rossini ET AL; ANMCO POSITION PAPER: Role of intra-aortic balloon pump in patients with acute advanced heart failure and cardiogenic shock.Eur
Heart J Suppl. 2021 Aug.

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