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Non-Coronary Intervention

Circulatory Support

Advanced Angioplasty 2003

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 ccballoon

Triggered to inflate withhelium immediately afteraortic valve closure

Triggered to deflate withopening of the aorticvalve

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Decreases Afterload

Increases Diastolic Aortic Pressure

Increases Coronary Flow Velocity

Reduces Myocardial Oxygen Demand

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Circulatory Support


Results & Evidence

Guidelines


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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


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Benchmark Registry:

Indication

Hemodynamic support during/after

catheterisation 20.6%

Cardiogenic shock 18.8%

Weaning from CP bypass 16.1%

Preoperative use in high risk pts 13% Refractory unstable angina 12.3%


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Benchmark Registry: Complications

Major: Limb ischemia, severe bleeding,balloon leak, death due to IABP 2.6%

Inhospital mortality 21.2% Failed IABP insertion 2.3%

Increased risk for major complications:

Women

Low BSA

Older patients

PVDFerguson et al. J Am Coll Cardiol 2001; 38:1456

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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


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High risk

Age>70yrs

3 vessel disease

LVEF

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N:1100 Angio for MI

N: 908 randomisedN: 437 high risk

IABP 211 no IABP 226

Established 86% Crossover 13%


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4.3 3.1 6.2

8

6.7 5.52.4

0

19.9

23

28.9 29.2

0

5

10

15

20

25

30

Death Re-MI Reoccl Stroke CHF

Hypo

Endpoint

IABP

no IABP

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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

Complications

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IABP Evidence

A randomized comparison of intraaortic

balloon pumping after primary coronary

angioplasty in high risk patients withacute MI treated

Van t Hoft 1999, Eur Heart J

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IABP Evidence

Van t Hoft 1999, Eur Heart J

N 238 over 3.5 years

118 IABP 120 no IABP

Primary endpoint: Death, Re-MI, stroke, EF 26% vs 26%

No difference in EF

8% major complications in IABP group

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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

Sanborn et al. J Am Coll Cardiol 2000; 36:1123

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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SHOCK Registry


N: 856 patients with cardiogenic shock in acute MI

36 participating centres

Treatment:

No thrombolysis / no IABP 33%

IABP only 33%

Thrombolysis only 15%

Thrombolysis and IABP 19%

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p

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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 IABPgroup

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Circulatory Support


Results & Evidence

Guidelines


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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 thecontralateral 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 VSDas a stabilising therapy for angio and repair/

revascularisation

Recurrent intractable ventricular arrhythmias with hemodynamic

instability

Refractory postMI 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 persistentischemia 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 ofhemodynamically unstable patients

especially in the setting of acute MI

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Circulatory Support


Results & Evidence

Guidelines


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Assist Devices: Indications

Cardiogenic shock in AMI

Postsurgical myocardial dysfunction

Acute cardiac failure from myocarditis

Decompensated chronic heart failure

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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 wont fix with

percutaneous intervention

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