Elsevier

American Heart Journal

Volume 199, May 2018, Pages 181-191
American Heart Journal

Clinical Investigation
Predictors of intra-aortic balloon pump hemodynamic failure in non-acute myocardial infarction cardiogenic shock

https://doi.org/10.1016/j.ahj.2017.11.016Get rights and content

Objectives

To characterize patient profile and hemodynamic profile of those undergoing intra-aortic balloon pump (IABP) for cardiogenic shock and define predictors of hemodynamic failure of IABP support.

Background

Clinical characteristics of IABP support in cardiogenic shock not related to acute myocardial infarction (AMI) remain poorly characterized.

Methods

We retrospectively studied a cohort of 74 patients from 2010 to 2015 who underwent IABP insertion for cardiogenic shock complicating acute decompensated heart failure not due to AMI.

Results

In the overall cohort, which consisted primarily of patients with chronic systolic heart failure (89%), IABP significantly augmented cardiac index and lowered systemic vascular resistance (P < .05). Despite this improvement, 28% of these patients died (24%) or require urgent escalation in mechanical circulatory support (MCS) (4%). Multivariable regression revealed that baseline left ventricular cardiac power index (LVCPI), a measure of LV power output derived from cardiac index and mean arterial pressure (P = .01), and history of ischemic cardiomyopathy (P = .003) were significantly associated with the composite adverse-event endpoint of death or urgent MCS escalation. An IABP Failure risk score using baseline LVCPI <0.28 W/m2 and ischemic history predicted 28-day adverse events with excellent discrimination.

Conclusion

Despite hemodynamic improvements with IABP support, patients with non-AMI cardiogenic shock still suffer poor outcomes. Patients with ischemic cardiomyopathy and low LVPCI fared significantly worse. These patients may warrant closer observation or earlier consideration of more advanced hemodynamic support.

Section snippets

Patient population and outcomes

A retrospective analysis was performed of all consecutive adult patients (age  18 years) hospitalized at a single tertiary-care hospital between July 2010 and June 2015 that underwent placement of an intra-aortic balloon pump. The study was approved by the institutional review board of the Johns Hopkins Medical Institution.

The target study population comprised patients with known or newly diagnosed cardiomyopathy who required IABP for treatment of cardiogenic shock. Patients were excluded if

Cohort characteristics

Out of the 474 patients who underwent IABP placement at Johns Hopkins Hospital between 2010 and 2015, 400 patients were excluded, yielding 74 patients in the final cohort. (Figure 1). These patients all had known or newly diagnosed cardiomyopathy and underwent IABP placement for the treatment of cardiogenic shock complicating non-AMI heart failure. The vast majority of these patients had cardiogenic shock complicating a known cardiomyopathy (89%). Of the 74 patients, 15 patients (20%) survived

Discussion

IABP counter-pulsation remains poorly studied in the setting of cardiogenic shock in the non-AMI setting. The current study identifies a cohort of non-AMI patients requiring IABP for cardiogenic shock and finds that despite initial hemodynamic improvement, nearly 30% of patients failed IABP support and went on to die or require urgent escalation in MCS. Low LVCPI (< 0.28 W/m2) at time of IABP implantation and history of ischemic cardiomyopathy proved to be the most powerful predictors of IABP

Conclusions

Despite significant hemodynamic improvement from IABP support in the treatment of cardiogenic shock in the non-AMI setting, many patients still fare poorly. In our cohort of cardiogenic shock patients undergoing IABP, low LVCPI (<0.28 W/m2) at the time of IABP implantation and history of ICM helped to predict significantly poorer 28-day outcomes. This may represent a cohort that warrants up-front consideration of more advanced MCS support, or at least close monitoring and consideration of MCS

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Author disclosures: All authors have no relationships with industry.

Financial Support: This study was supported by the National Institutes of Health-National Heart, Lung, and Blood Institute (T32-HL007227-40, S.H.).

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