Advanced Angioplasty 2003

Non-Coronary Intervention

Circulatory Support
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 cc balloon Triggered to inflate with helium immediately after aortic valve closure Triggered to deflate with opening of the aortic valve
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Intra-Aortic Balloon Pump

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Intra-Aortic Balloon Pump

Decreases Afterload Increases Diastolic Aortic Pressure Increases Coronary Flow Velocity

Reduces Myocardial Oxygen Demand

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Circulatory Support
Balloon Counterpulsation

Results & Evidence

Guidelines Assist Devices: Developments
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Intra-Aortic Balloon Pump 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

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

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Benchmark Registry: Indication

Hemodynamic support during/after catheterisation Cardiogenic shock Weaning from CP bypass Preoperative use in high risk pts Refractory unstable angina 20.6% 18.8% 16.1% 13% 12.3%

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

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Benchmark Registry: Complications

Major: Limb ischemia, severe bleeding, balloon leak, death due to IABP 2.6% In hospital mortality 21.2%

Failed IABP insertion

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2.3%

Increased risk for major complications:

Women Low BSA Older patients PVD

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

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

Stone et al. J Am Coll Cardiol 1997
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IABP in direct angioplasty

High risk
Age>70yrs 3 vessel disease LVEF<45% SVG occlusion Persistent malignant arrhythmia Subotpimal result*
Stone et al. J Am Coll Cardiol 1997
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*Stents 1.3%

IABP in direct angioplasty

N:1100 Angio for MI N: 908 randomised N: 437 high risk IABP 211 Established 86%

no IABP 226 Crossover 13%

Stone et al. J Am Coll Cardiol 1997

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IABP in direct angioplasty

30 25 20 15 10 5 0
Death
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28.9 29.2 23 19.9

IABP no IABP

8 4.3 3.1 6.2 6.7 5.5 2.4 0

Re-MI Reoccl Stroke CHF Hypo Endpoint

Stone et al. J Am Coll Cardiol 1997

IABP in direct angioplasty

Complications
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
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Stone et al. J Am Coll Cardiol 1997

IABP Evidence
A randomized comparison of intraaortic balloon pumping after primary coronary angioplasty in high risk patients with acute MI treated
Van t Hoft 1999, Eur Heart J

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IABP Evidence
N 238 over 3.5 years

118 IABP

120 no IABP

Primary endpoint: Death, Re-MI, stroke, EF<30% at 6 months FU -> 26% vs 26%

No difference in EF 8% major complications in IABP group

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Van t Hoft 1999, Eur Heart J

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

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

SHOCK Registry
N: 856 patients with cardiogenic shock in acute MI 36 participating centres Treatment: No thrombolysis / no IABP IABP only Thrombolysis only Thrombolysis and IABP 33% 33% 15% 19%

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

SHOCK Registry: Mortality

Cardiogenic shock (LV Failure)

No thrombolysis n=564 64%

Thrombolysis n=292 54%

p=.005

No IABP n=285 77%

IABP n=279 52%

No IABP n=132 63%

IABP n=160 p<.0001 47%

no revasc n=233 83%

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revasc n=52 48%

no revasc n=84 76%

revasc n=195 41%

no revasc n=105 74%

revasc n=27 19%

no revasc n=51 69%

revasc n=109 37%

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

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 IABP group
Sanborn et al. J Am Coll Cardiol 2000; 36:1123
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Circulatory Support
Balloon Counterpulsation
Results & Evidence

Guidelines
Assist Devices: Developments
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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 the contralateral 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 VSD as a stabilising therapy for angio and repair/ revascularisation

Recurrent intractable ventricular arrhythmias with hemodynamic instability

Refractory post MI 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 persistent ischemia 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 of hemodynamically unstable patients especially in the setting of acute MI

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Circulatory Support
Balloon Counterpulsation
Results & Evidence Guidelines

Assist Devices: Developments

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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

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(ABIOCOR)

Delgado et al Circulation 2002;106:2046

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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