Impact of timing of intraaortic balloon counterpulsation on mortality in cardiogenic shock – a subanalysis of the IABP-SHOCK II trial

Abstract

Background Conflicting results exist on whether initiation of intraaortic balloon pumping (IABP) before percutaneous coronary intervention (PCI) has an impact on outcome in this setting. Our aim was to assess the outcome of patients undergoing IABP insertion before versus after primary PCI in acute myocardial infarction complicated by cardiogenic shock. Methods The IABP-SHOCK II-trial randomized 600 patients with acute myocardial infarction and cardiogenic shock to IABP-support versus control. We analysed the outcome of patients randomized to the intervention group regarding timing of IABP implantation before or after PCI. Results Of 600 patients included in the IABP-SHOCK II trial, 301 were randomized to IABP-support. We analysed the 275 (91%) patients of this group undergoing primary PCI as revascularization strategy surviving the initial procedure. IABP insertion was performed before PCI in 33 (12%) and after PCI in 242 (88%) patients. There were no differences in baseline arterial lactate ( p = 0.70), Simplified Acute Physiology Score-II-score ( p = 0.60) and other relevant baseline characteristics. No differences were observed for short- and long-term mortality (pre vs. post 30-day mortality: 36% vs. 37%, odds ratio 0.99, 95% confidence interval (CI) 0.47–2.12, p = 0.99; one-year mortality: 56% vs. 48%, hazard ratio 1.08, 95% CI 0.65–1.80, p = 0.76; six-year-mortality: 64% vs. 65%, hazard ratio 1.00, 95% CI 0.63–1.60, p = 0.99). In multivariable Cox regression analysis timing of IABP-implantation was no predictor for long-term outcome (hazard ratio 1.08, 95% CI 0.66–1.78, p = 0.75). Conclusions Timing of IABP-implantation pre or post primary PCI had no impact on outcome in patients with acute myocardial infarction complicated by cardiogenic shock.

Microaxial circulatory support for percutaneous coronary intervention: A systematic review and meta‐analysis

“…Studies exploring the use of IABP do not demonstrate a consistent relationship between timing of device initiation and survival in PCI for AMICS. Some of these studies illustrate no association between timing of IABP initiation and survival, [28][29][30][31] while results from a retrospective cohort study suggested that only pre-PCI IABP may improve survival. 32 Other studies comparing IABP to Impella include limitations that may yield different conclusions once reconciled.…”

Retrospective Analysis of Intra-Aortic Balloon Pump Use in Cardiology Ward Patients Undergoing Coronary Angiography between 2012 and 2020

“…There were no differences between patient survival and death according to the timing of counter-pulsation insertion, similar to a study that aimed to evaluate the outcomes of patients undergoing IABP insertion before vs. after primary PCI in acute myocardial infarction that were complicated by cardiogenic shock. The analysis included 275 patients, and the timing of IABP implantation before or after primary PCI did not affect the outcomes in these patients [ 15 ]. In large randomized controlled trials in patients with acute coronary syndrome (ACS) and high-risk percutaneous coronary intervention (PCI), there was no benefit of IABPs in reducing the infarct size and no difference in major adverse cardiac and cerebrovascular events (MACCE) between patients undergoing high-risk PCI, either with or without IABP support.…”

A Comprehensive Review of Mechanical Circulatory Support Devices

“…The timing of MCS device insertion may be critical in certain clinical situations. 9,10 In AMI-CS, MCS devices should be inserted as soon as possible if the initial resuscitative attempts with conventional pharmacological support fail, and preferably before PCI. 11 This was explored in a multidisciplinary team-based protocol, the National Cardiogenic Shock Initiative, which used a standardized treatment algorithm to improve the effectiveness of MCS devices in AMI-CS.…”