Intra-aortic balloon pump: is the tide turning?

• Users may freely distribute the URL that is used to identify this publication. • Users may download and/or print one copy of the publication from the University of Birmingham research portal for the purpose of private study or non-commercial research. • User may use extracts from the document in line with the concept of ‘fair dealing’ under the Copyright, Designs and Patents Act 1988 (?) • Users may not further distribute the material nor use it for the purposes of commercial gain.

recent meta-analysis, for example, included 9212 patients and investigated the utility of the IABP when implanted preoperatively in patients undergoing coronary bypass graft surgery [6]. The results of this analysis strongly indicate that there is benefit in using the IABP under these conditions, with the relative risk reduction of mortality being more than 4%. Furthermore, the risk of MI and renal failure were reduced when IABP treatment was instigated and both intensive care and total hospital stays were reduced, also indicating a possible economic benefit, as well as health benefit, of using the IABP [6].
Likewise, a recent study by Yang et al. [7], carried out in 416 patients with LV dysfunction undergoing off-pump coronary bypass grafting, showed that a preoperative IABP was linked with a lower 30-day mortality.
Interestingly, Iqbal et al. [8] recently carried out an observational analysis of 174 patients (with 55 patients receiving IABP) successfully resuscitated following an out-of-hospital cardiac arrest. In this study, the use of IABP therapy in the postresuscitation period was associated with improved functional recovery and outcomes, although the mortality rate was not different between the IABP and non-IABP groups [8].
Imamura et al. [9] recently showed that an elevation in central venous pressure and a lower heart rate were a predictor for significant hemodynamic response to IABP treatment in a population of decompensated heart failure patients. A very recent study [10] indicated that the IABP was associated with a lower risk of 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock, in whom percutaneous coronary intervention was unsuccessful, whilst a higher risk of death was seen in patients where PCI had been successful. Taken together, these data indicate that improved patient selection may greatly influence outcomes.
Interestingly, use of the IABP together with other support systems, such as extracorporeal membrane oxygenation (ECMO), has also been receiving increased attention over recent years [11]. For example, a recent study by Meani et al. [12] showed the potential utility of the IABP to reverse aortic valve closure and impaired left ventricular unloading that occurs during V-A ECMO support, whilst Bréchot et al. [13] showed that the association of IABP with V-A ECMO was associated with a lower frequency of pulmonary edema. Further research, both at the basic and the clinical level, is, however, required to fully understand the utility of such combination therapy.
Is the tide turning? At this stage, it is too early to say and we should be prudent, whilst at the same time critical, when examining studies. Nevertheless, the heavy debate on appropriate use of the IABP needs new lifeblood from numerous avenues including cardiologists, intensivists, anesthesiologists and cardiac surgeons. These specialties need to work together to actively contribute to a rigorous and objective data collection/examination/analysis. Furthermore, a key role needs to be played by companies involved in IABP development, who should, in our opinion, show an interest in gaining new scientific evidence to aid the scientific community in filling the considerable gap currently existing between guidelines and clinical practice.
In conclusion, maybe the time is right for new well-designed clinical trials to cause an "After-SHOCK II" in the field of IABP support. Only these data will properly inform the community whether there is some nice weather on the horizon or whether we just have a temporary rainbow.  Adapted from [14] with permission