主动脉内球囊反搏在急性心肌梗死合并泵衰竭急诊介入中的辅助治疗

目的　评价在急性心肌梗死 (AMI)合并泵衰竭急诊介入中辅以主动脉内球囊反搏(IABP)治疗的安全性及有效性。方法　对 87例合并严重泵衰竭甚或心源性休克的AMI患者行急诊介入治疗。将 2 1例 (2 4% )同时接受IABP辅助治疗的患者设为IABP组 (A组 ) ,另 6 6例 (76 % )设为对照组 (B组 )。比较两组临床特征、冠状动脉造影情况及住院期的临床疗效。结果　年龄、性别、发病初始至导管室时间、心肌梗死部位、冠状动脉病变支数、具体梗死相关动脉 (IRA)及血管重建术前梗死相关动脉血流TIMI分级等指标 ,A、B两组之间无统计学差异。心功能分级 (Killip分级 ) ,A组较B组严重 ;而住院期间 ,A组死亡率及血管再闭塞事件较B组明显降低。结论　对于高危AMI合并泵衰竭 ,尤其心源性休克的患者 ,在行急诊介入时 ,IABP的辅助使用明显降低住院期死亡率 ,减少血管再闭塞率 ,提高手术成功率 ,其远期预后有待进一步随访。     

The use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2

BACKGROUND: Cardiogenic shock complicating acute myocardial infarction (AMI) remains the leading cause of death in patients hospitalized with AMI. Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery, it remains unclear as to whether intra-aortic balloon counterpulsation (IABP) provides incremental benefit to reperfusion therapy. The purpose of this study was to determine whether IABP use is associated with lower in-hospital mortality rates in patients with AMI complicated by cardiogenic shock in a large AMI registry. METHODS: We evaluated patients participating in the National Registry of Myocardial Infarction 2 who had cardiogenic shock at initial examination or in whom cardiogenic shock developed during hospitalization (n = 23,180). RESULTS: The mean age of patients in the study was 72 years, 54% were men, and the majority were white. The overall mortality rate in all patients who had cardiogenic shock or in whom cardiogenic shock developed was 70%. IABP was used in 7268 (31%) patients. IABP use was associated with a significant reduction in mortality rates in patients who received thrombolytic therapy (67% vs 49%) but was not associated with any benefit in patients treated with primary angioplasty (45% vs 47%). In a multivariate model, the use of IABP in conjunction with thrombolytic therapy decreased the odds of death by 18% (odds ratio, 0.82; 95% confidence interval, 0.72 to 0.93). CONCLUSIONS: Patients with AMI complicated by cardiogenic shock may have substantial benefit from IABP when used in combination with thrombolytic therapy.     

Impact of the Change in ESC Guidelines on Clinical Characteristics and Outcomes of Cardiogenic Shock Patients Receiving IABP Therapy

BackgroundIntra-aortic balloon pump (IABP) counterpulsation provides mechanical support for patients with cardiogenic shock. The aim of the study is to evaluate the clinical characteristics and outcomes of patients with cardiogenic shock receiving IABP before and after the European Society of Cardiology (ESC) downgraded the use of IABP from a class I to a class IIb in 2012.MethodsData was obtained from the Acute Coronary Syndrome Israeli Survey (ACSIS) registry, a prospective observational national survey conducted once every two years. From a total of 15,200 patients with acute coronary syndrome (ACS), 524 patients were identified with acute myocardial infarction (AMI)-complicated with cardiogenic shock. The groups were further subdivided based on whether the IABP was implanted before or after the change in guideline recommendation.ResultsThe study indicates a 24% reduction in IABP use since 2002. Until 2012, a reduction in clinical outcomes including 7-days, 30-days and in-hospital mortality, was observed in patients with IABP compared to the patients with conventional therapy. Conversely, after the ESC changed the guidelines, the clinical outcomes were not improved by IABP treatment. Additionally, the conventional therapy group presented with higher baseline ejection fraction, received less effective treatment, reperfusion and/or pharmacological therapy than patients with IABP.ConclusionThe use of IABP as management for cardiogenic shock has diminished over time since the guidelines were modified. After the change in guidelines, the use of IABP is restricted to high-risk, severely compromised and hemodynamically deteriorated patients hence limiting beneficial outcomes.     

Prophylactic intraaortic balloon pumping preserves left ventricular systolic function in acute anterior myocardial infarction without cardiogenic shock

OBJECTIVES: Left ventricular function and prognosis were evaluated in patients with acute myocardial infarction who underwent primary percutaneous coronary intervention supported by intraaortic balloon pumping. METHODS: Fifty-eight consecutive patients with first acute myocardial infarction were treated between July 1999 and April 2006. Twenty-five had cardiogenic shock on admission, whereas 33 did not. Patients with anterior acute myocardial infarction without cardiogenic shock were divided into the prophylactic intraaortic balloon pumping group (Group 1; n=17) and the rescue intraaortic balloon pumping group (Group 2; n=9). RESULTS: Thirty-day in-hospital mortality was 52% in cardiogenic shock patients, and 3% in non-shock patients. Baseline characteristics of non-shock anterior acute myocardial infarction were similar including Thrombolysis in Myocardial Infarction (TIMI) risk scores (5.1 and 5.0) in the two groups. However, average left ventricular ejection fraction in the convalescent stage was superior in Group 1 (48.7% vs. 37.8%, p = 0.03). Thirty-day in-hospital mortality was 0% in Group 1 and 11% in Group 2 (p = 0.34). Cox's hazard ratio in Group 2 to Group 1 was 2.38 (95% confidence intrerval; 0.84-11.1, p = 0.09) in terms of the subsequent major cardiac events. CONCLUSIONS: Prophylactic use of intraaortic balloon pumping starting prior to primary percutaneous coronary intervention preserves the convalescent left ventricular systolic function in patients with high risk for anticipated cardiac events after anterior acute myocardial infarction without cardiogenic shock.     

主动脉内球囊反搏在急性心肌梗死治疗中的应用

目的分析和评价主动脉内球囊反搏(IABP)在急性心肌梗死治疗中的应用效果。方法收集2000年1月1日至2006年12月31日期间,北京大学第一医院心内科所有应用IABP的急性心肌梗死患者的临床资料。应用统计学方法分析IABP的治疗效果。结果应用IABP治疗急性心肌梗死患者共48例,其中合并心源性休克26例。应用IABP的急性心肌梗死患者即刻病情改善率为81.3%。与单纯IABP亚组相比,IABP联合后续治疗(经皮冠状动脉介入治疗/外科手术)亚组的院内死亡率显著下降(37.5%比93.8%,P<0.01)。结论应用IABP治疗可改善急性心肌梗死患者的即刻病情,IABP降低急性心肌梗死患者院内死亡率的关键是联合后续治疗。     

高龄冠状动脉左主干病变合并心源性休克直接PCI治疗2例并文献复习

目的探讨左主干病变导致急性心肌梗死合并心源性休克的高龄（年龄≥75岁）患者在主动脉内球囊反搏（intra-aortic balloon pump,IABP）支持下经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗的可行性。方法回顾性分析2例90岁以上高龄左主干病变合并心源性休克患者在IABP支持下行直接PCI治疗的临床资料并复习相关文献。结果在给予IABP支持下,PCI治疗可恢复灌注以纠正休克,患者血流动力学和神经病学恢复正常,住院期间存活良好。结论在IABP支持下,直接PCI治疗可以拯救高龄患者生命并改善预后,是一种安全有效的临床选择。     

Efficacy of percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock.

Cardiogenic shock still remains a highly lethal complication of acute myocardial infarction (AMI). This study reviews our hospital experience in treating AMI complicated by cardiogenic shock to evaluate whether coronary angioplasty improves survival or not. We have treated 523 AMI patients from 1985 to 1990, and among these, 26 patients with AMI complicated by cardiogenic shock who underwent percutaneous transluminal coronary angioplasty (PTCA) compose the study group. In 16 patients, PTCA was successful (Groups S) and in 10 patients, unsuccessful (Group F). There were no statistical differences between the Groups with respect to clinical background, intraaortic balloon counterpulsation (IABP) or emergency coronary bypass graft surgery. Before PTCA, hemodynamic variables including cardiac index, pulmonary capillary wedge pressure and systolic blood pressure were similar in the 2 groups. After PTCA, cardiac index in Group S patients was better than in Group F patients (2.18 +/- 0.61 versus 1.62 +/- 0.65, p less than 0.05). Thirty day and 1 year survivals were also better in Group S than in Group F (30 day survival: Group S 56.2%, Group F 10%, 1 year survival: Group S 31.2%, Group F 0%, p less than 0.05). Multivariate analysis showed that age under 75 years old, systolic blood pressure over 90 mmHg after PTCA and successful PTCA were independent predictors of 30 day survival (p less than 0.05). It was suggested that PTCA was an effective procedure to reduce mortality in patients with cardiogenic shock.     

主动脉内球囊反搏术在急性心肌梗死治疗中的应用和对近期预后的影响

目的了解急性心肌梗死（AMI）治疗中主动脉内球囊反搏术（IABP）的应用、并发症发生率和对近期预后的影响。方法单中心注册研究。连续入选2004年10月至2008年7月间,就诊于北京安贞医院28病房置入IABP的所有AMI患者。结果806例AMI患者中,共有121例（15.0%）置入IABP。最常见指征为高危冠状动脉（冠脉）造影和（或）PCI术中和术后提供血流动力学支持（66.9%）和心源性休克（26.4%）。IABP置入成功率为98.3%,平均使用时间为34±16h。严重并发症发生率为0%。所有患者均进行了冠脉造影,93.4%在出院前施行了冠脉血管重建。总住院死亡率为13.2%（其中心源性休克患者34.4%）,住院死亡率因置入IABP指征不同和施行冠脉血管重建与否存在很大差异。结论IABP可成功应用于AMI的多种高危状况并提供必要的血流动力学支持,严重并发症罕见,联合冠脉血管重建治疗可降低死亡率。     

主动脉内球囊反搏在急性心肌梗死合并心源性休克治疗中的应用

目的评价主动脉球囊反搏术(IABP)在急性心肌梗死(AMI)合并心源性休克治疗中的应用价值。方法选取AMI合并心源性休克患者65例,其中IABP组30例,在IABP支持下行急诊经皮冠状动脉介入治疗(PCI),对照组35例,单纯行急诊PCI治疗。结果IABP组患者在IABP支持下,30 min后血流动力学指标改善,2~8 h血流动力学稳定,均完成梗死相关血管再通,没有血管再闭塞事件发生,无术中死亡,院内死亡率40%;对照组患者院内死亡率74.3%,其中6例在术中死亡。结论IABP可明显改善AMI合并心源性休克患者的血流动力学指标,增加冠状动脉的灌注;IABP可提高急诊PCI的成功率,减少术后低心排综合征及血管再闭塞事件的发生,降低院内死亡率,明显改善了AMI合并心源性休克患者的预后。     

急性心肌梗死合并心原性休克47例治疗和死亡原因分析

目的 评价急性心肌梗死合并心原性休克47例患者的临床疗效,寻求降低病死率、改善预后的措施.方法 回顾性分析2002年1月至2007年5月共47例心肌梗死合并心原性休克患者,运用心血管活性药物、主动脉内球囊反搏(IABP)、介入手术或冠状动脉旁路移植术的治疗效果.结果 IABP治疗47例(100%),再血管化治疗41例(87.3%),死亡17例(36.2%).经药物和IABP治疗,在接受再血管化前死亡的患者占死亡数的35.3%(6/17),再血管化后死亡的患者占死亡数的64.7%(11/17).死于心功能衰竭者9例,死于肾功能衰竭和呼吸功能衰竭者8例.11例出现急性肾功能衰竭的患者全部死亡.急性肾功能衰竭(r=0.734,P=0.000)、急性呼吸功能衰竭(r=0.606,P=0.000)和糖尿病(r=0.372,P=0.012)与死亡有相关关系.结论 尽管急性心肌梗死合并心原性休克的治疗有了很大的发展,但病死率仍然较高,主要死因是急性心力衰竭、急性肾功能衰竭和急性呼吸功能衰竭.要进一步降低急性心肌梗死合并心原性休克患者住院病死率,可能需要更好的循环辅助装置及加强重要器官的保护.     

Appropriate indications for the use of a percutaneous cardiopulmonary support system in cases with cardiogenic shock complicating acute myocardial infarction

Percutaneous cardiopulmonary support (PCPS) is now available for hemodynamic support in patients with cardiogenic shock, but there are no guidelines for its use. The present study determined the appropriate indications for the use of the PCPS in patients with cardiogenic shock complicating acute myocardial infarction (AMI). Sixty-four consecutive patients with cardiogenic shock complicating AMI had hemodynamic support with an intraaortic balloon pump (IABP; n=38) and/or PCPS (n=26). The shock score (0-15) was calculated immediately before starting these support systems to quantify the severity of shock. Multivariate logistic regression analysis determined the clinical factors affecting in-hospital mortality. The relationship between in-hospital prognosis and the shock score was also examined in the 2 groups. The most significant factor related to the in-hospital prognosis was the shock score (p=0.0007; OR 2.16, 95% CI: 1.37-3.39). Another related factor was revascularization; however, this relationship did not reach statistical significance (p=0.069; OR 0.06). Among the 13 cases whose shock score was 4-8 (moderate shock), 5 survived in the PCPS group, but only 1 of 19 patients survived in the IABP group (p<0.05). None of the patients in either group whose shock score was more than 9 survived. The severity of shock is the most reliable independent predictor of in-hospital mortality in patients with cardiogenic shock complicating AMI. Using PCPS in patients with moderate cardiogenic shock may improve their in-hospital survival, but it must be used before the shock becomes severe.     

Percutaneous coronary intervention for cardiogenic shock in the SHOCK Trial Registry

BACKGROUND: The SHOCK Registry prospectively enrolled patients with cardiogenic shock complicating acute myocardial infarction in 36 multinational centers. METHODS: Cardiogenic shock was predominantly attributable to left ventricular pump failure in 884 patients. Of these, 276 underwent percutaneous coronary intervention (PCI) after shock onset and are the subject of this report. RESULTS: The majority (78%) of patients undergoing angiography had multivessel disease. As the number of diseased arteries rose from 1 to 3, mortality rates rose from 34.2% to 51.2%. Patients who underwent PCI had lower in-hospital mortality rates than did patients treated medically (46.4% vs 78.0%, P < .001), even after adjustment for patient differences and survival bias (P = .037). Before PCI, the culprit artery was occluded (Thrombolysis In Myocardial Infarction grade 0 or 1 flow) in 76.3%. After PCI, the in-hospital mortality rate was 33.3% if reperfusion was complete (grade 3 flow), 50.0% with incomplete reperfusion (grade 2 flow), and 85.7% with absent reperfusion (grade 0 or 1 flow) (P < .001). CONCLUSIONS: This prospective, multicenter registry of patients with acute myocardial infarction complicated by cardiogenic shock is consistent with a reduction in mortality rates as the result of percutaneous coronary revascularization. Coronary artery patency was an important predictor of outcome. Measures to promote early and rapid reperfusion appear critically important in improving the otherwise poor outcome associated with cardiogenic shock.     

应用主动脉内球囊反搏结合血管重建术治疗急性心肌梗死并发泵衰竭患者的效果

目的:观察应用主动脉内球囊反搏（IABP）结合血管重建术治疗急性心肌梗死并发泵衰竭患者的效果。方法: 2004年12月~2010年12月我院确诊急性心肌梗死并发泵衰竭并应用IABP的住院患者75（男54,女21）例。按是否做血管重建术分为两组:血管重建组和非血管重建组。所有患者均在药物治疗的基础上行IABP,所用反搏仪为AUTO CAT2或Datascope 98 system,血管重建组并行冠状动脉造影及经皮冠状动脉介入术(PCI)或冠脉旁路移植术（CABG）。结果: 全部75例患者中,IABP反搏时间2～336（90±75） h;死亡22例,病死率29%;血管重建组中63例行PCI术,1例行择期CABG,术后死亡14例,病死率22%;非血管重建组中死亡8例,病死率73%。血管重建组的病死率显著低于非血管重建组（P<0.01）,并发症共5例,发生率7%。结论: 在IABP的支持下,积极进行血管重建治疗可以降低急性心肌梗死并发泵衰竭患者的住院期间病死率。     

Reperfusionstherapie und mechanische Kreislauf-unterstützung bei Patienten mit kardiogenem Schock

Cardiogenic shock is a state of inadequate tissue perfusion due to cardiac dysfunction, which is most commonly caused by acute myocardial infarction. The pathophysiology of cardiogenic shock is characterized by a downward spiral: ischemia causes myocardial dysfunction, which, in turn, augments the ischemic damage and the energetical imbalance. With conservative therapy, mortality rates for patients with cardiogenic shock are frustratingly high reaching more than 80%. Additional thrombolytic therapy has not been shown to significantly improve survival in such patients. Emergency cardiac catheterization and coronary angioplasty, however, seem to improve the outcome in shock-patients, which most probably is due to rapid and complete revascularization generally reached by angioplasty. In addition to interventional therapy with rapid coronary revascularization, the use of mechanical circulatory support may interrupt the vicious cycle in cardiogenic shock by stabilizing hemodynamics and the metabolic situation. Different cardiac assist devices are available for cardiologists and cardiac surgeons: 1. intraaortic balloon counterpulsation (IABP), 2. implantable turbine-pump (Hemopump), 3. percutaneous cardiopulmonary bypass support (CPS), 4. right heart, left heart, or biventricular assist devices placed by thoracotomy, and 5. intra- and extrathoracic total artificial hearts. Since percutaneous application is possible with IABP, Hemopump and CPS, these devices are currently used in interventional cardiology. The basic goals of the less invasive intraaortic balloon counterpulsation (IABP; Figure 1) are to stabilize circulatory collapse, to increase coronary perfusion and myocardial oxygen supply, and to decrease left ventricular workload and myocardial oxygen demand (Figure 2). Since the advent of percutaneous placement, IABP has been used by an increasing number of institutions (Figure 3). In addition to cardiogenic shock, the system may be of use in a variety of other indications in the catheterization laboratory and intensive care unit, including weaning from percutaneous cardiopulmonary bypass, in ischaemic left ventricular failure, in unstable angina, in high risk PTCA, and in prophylactic support in patients with myocardial infarction and successful revascularization. Animal experimental data showed that IABP may improve success of thrombolysis and recent clinical data suggest that survival is enhanced and transfer for revascularization is facilitated when patients with myocardial infarction and cardiogenic shock undergo thrombolysis and IABP rather than thrombolysis alone. A lot of studies had demonstrated before, that combined use of counterpulsation and revascularization therapy (i.e. coronary bypass surgery or angioplasty) may improve prognosis in patients with myocardial infarction complicated by cardiogenic shock (Table 1). In such patients, early treatment with IABP is most important: Multivariate analysis identified early IABP-support with a duration of shock to IABP-treatment of > or = 4 hours as an independent predictor of a positive short-term outcome. In shock-patients with postinfarction ventricular septal defect, IABP provides a marked hemodynamic improvement, and a significant decrease in shunt-flow (Figure 5). However, despite initial stabilization with IABP, such patients need immediate surgical repair of the septal defect to avoid hemodynamic deterioration. The rate of complications related to percutaneous IABP was significantly attenuated by employing catheters of reduced size. Using 9.5-F catheters, a long duration of counterpulsation emerged as the most significant factor associated with complications. In our hospital, those patients with 9.5-F catheters in whom counterpulsation did not exceed 48 hours had a low complication rate of 3.9%. The Hemopump is a catheter-mounted transvalvular left ventricular assist device intended for surgical placement via the femoral artery (Figures 6 and 7). (ABSTRACT TRUNCATED)     

Emergent angioplasty prevents left ventricular dilation in patients with acute anterior wall myocardial infarction and cardiogenic shock

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) reduces in-hospital mortality and improves long-term outcome in patients with acute myocardial infarction (MI) complicated by cardiogenic shock. However, no study has evaluated the effects of different reperfusion therapies on left ventricular (LV) dimension and cardiac function in long-term survivors of MI with cardiogenic shock. HYPOTHESIS: We investigated the effects of PTCA on the development of LV dilation in patients who survived MI complicated by cardiogenic shock. METHODS: We studied 34 patients with a first MI and cardiogenic shock in whom two-dimensional echocardiography was performed immediately after admission and 1 month after infarction. Group A consisted of 17 patients who underwent emergent PTCA during the acute phase of MI, and Group B consisted of 17 patients who did not undergo PTCA. We also studied 119 patients with a first uncomplicated acute anterior MI, including 53 who underwent PTCA (Group C) and 66 who did not (Group D). The length and wall thickness of the infarcted and noninfarcted endocardial segments were determined immediately after MI and 1 month later, and LV ejection fraction (LVEF) was measured during the chronic phase. RESULTS: The lengths of the infarcted and noninfarcted endocardial segments were significantly greater in Group B than in the other three groups (p < 0.05). The LVEF was significantly lower in Group B than in the other three groups (p < 0.05). CONCLUSIONS: We conclude that PTCA performed in patients during the acute phase of MI complicated by cardiogenic shock lowers in-hospital mortality and prevents both LV dilation and a decrease in LVEF.     

Pathophysiology, diagnosis, and treatment of infarction-related cardiogenic shock

Cardiogenic shock is characterized by inadequate tissue perfusion due to cardiac dysfunction, and it is often caused by acute myocardial infarction. The mortality rate in patients with cardiogenic shock is still very high (i.e., 50?C60%). The pathophysiology of cardiogenic shock involves a vicious spiral circle: ischemia causes myocardial dysfunction, which in turn aggravates myocardial ischemia. Myocardial stunning and/or hibernating myocardium can enhance myocardial dysfunction, thus, worsening the cardiogenic shock. Low perfusion pressures with global ischemia leads to multiorgan dysfunction. Ischemia and reperfusion can result in systemic inflammation or within the first few days sepsis due to the translocation of bacteria or bacterial toxins from the intestines, which can result in increased mortality. The key to an optimal treatment of cardiogenic shock patients is a structured approach: (1)?rapid diagnosis and prompt initiation of therapy to increase blood pressure and augment cardiac output with subsequently improved perfusion. (2)?Rapid coronary revascularization is of critical importance. Using this approach, mortality can be reduced. In many hospitals, initial stabilization is achieved by intraaortic balloon counterpulsation (IABP). However, evidence for improved survival from randomized studies on the use of IABP in combination with PCI is lacking. (3)?In order to achieve adequate perfusion, dobutamine and sometimes in combination with norepinephrine might be necessary. Recent studies have shown that the calcium sensitizer levosimendan in cardiogenic shock can be a useful addition to medical therapy. In this overview, epidemiology, pathophysiology, and guideline-oriented treatment strategies for cardiogenic shock are presented.     

Predictors of in-hospital mortality in 1333 patients with acute myocardial infarction complicated by cardiogenic shock treated with primary percutaneous coronary intervention (PCI); Results of the primary PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhaus?rzte (ALKK).

Aims Acute myocardial infarction complicated by cardiogenic shock is associated with an exceedingly high mortality, even if patients are treated with early reperfusion therapy. The aim of this study was to evaluate predictors of in-hospital mortality of a large cohort of consecutive patients with cardiogenic shock treated with primary percutaneous coronary intervention (PCI). Methods and results Between July 1994 and March 2001 all interventions performed in 80 centres in Germany were prospectively entered into the primary PCI registry of the ALKK. A total of 9422 procedures were registered, of these 1333 (14.2%) were performed in patients with cardiogenic shock. Total in-hospital mortality was 46.1% and was dependent on TIMI flow grade after PCI, with mortality rates of 78.2%, 66.1% and 37.4% in patients with TIMI 0/1, TIMI 2 and TIMI 3 flow, respectively. In a multivariate analysis left main disease, TIMI <3 flow after PCI, older age, three-vessel disease and longer time-intervals between symptom onset and PCI were significant independent predictors of mortality. The relative number of PCIs performed in patients with cardiogenic shock did not change significantly from 1995-2000. There was a significant decrease in mortality over the years (P for trend 0.02). Conclusions In-hospital mortality in patients with acute myocardial infarction complicated by cardiogenic shock remains high, even with early interventional therapy. However, our data demonstrate that the PCI in these high-risk patients is feasible in a wide spectrum of community hospitals with acceptable success rates. Our results seen in connection with the results of the randomized SHOCK study advocate an early invasive approach in younger patients with cardiogenic shock, while the best strategy in elderly patients is still a matter of debate.     

Intraaortic balloon counterpulsation: an eleven-year review and analysis of determinants of survival

During an 11-year period ending January 1, 1985, 352 patients had insertions of an intraaortic balloon pump (IABP) as an adjunct to medical or surgical therapy. Group I, 175 patients, could not be weaned from cardiopulmonary bypass and required intraaortic balloon pump (IABP). Thirty-nine patients (22%) died in the operating room. Twenty-five patients (14%) died in the acute care unit. The remaining 111 patients (63.4%) survived and were discharged from the hospital. Group II, 104 patients, had the IABP inserted preoperatively. Indications were: postinfarction cardiogenic shock (34 patients), unstable angina (35), postinfarction angina (27), poor ventricular function (six), and prophylaxis (two). Of the 62 patients with unstable angina and postinfarction angina, 57 (92%) were successfully weaned. Of the 34 patients with postinfarction cardiogenic shock, 26 were weaned, but only 16 (47%) survived to leave the hospital. Group III, 34 patients, had the IABP inserted for postoperative hemodynamic deterioration in the acute care unit at variable times: 14 (41%) patients survived. Group IV, 39 patients, had IABP support for medical therapy. Of 24 patients with postinfarction cardiogenic shock, 12 survived. Twelve of 13 patients with unstable angina lived. Of the 352 patients, 228 (65%) were discharged from the hospital. The overall incidence of complications was 12.5%. Complications related to IABP were higher with percutaneous insertion than by femoral arteriotomy (15% vs 12%). Intraaortic balloon counterpulsation effectively unloads the failing left ventricle in weaning patients from cardiopulmonary bypass (Group I). Preoperative insertion (Group II) resulted in 92% survival in patients with both pre- and postinfarction angina. Delayed insertion (Group III) in postoperative patients gave the poorest survival (41%). In patients with postinfarction cardiogenic shock, IABP without corrective cardiac surgery was associated with a 50% survival: with corrective cardiac surgery, 16 patients (47%) survived. Left ventricular dysfunction, myocardial infarction, and timely insertion of IABP are the primary determinants of survival. Approximately one-third of patients who required IABP will die. More involved techniques for mechanical support of the failing circulation, such as ventricular assist device or total artificial heart, may increase survival.     

Möglichkeiten und Grenzen der interventionellen Therapie bei akuter Herzinsuffizienz bei koronarer Herzerkrankung

Acute heart failure and especially its most severe form, cardiogenic shock, remain the final common pathway to death in a substantial number of patients with acute myocardial infarction (MI). Several studies demonstrated that mechanical reperfusion of occluded coronary arteries by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery improves survival in patients with acute MI and cardiogenic shock. There is strong evidence that intraaortic balloon pump (IABP) support and ventricular assist devices can stabilize hemodynamics in these patients so that revascularization procedures can be safely performed. This article provides an overview of the therapeutic strategies for acute MI with cardiogenic shock, with focus on the role and particularities of different devices used as mechanical circulatory support in these patients.