Intra-aortic Balloon Pump May Best Inotropes in Decompensated HF

Neil Osterweil

May 27, 2019

PARIS — Early implantation of an intra-aortic balloon pump (IABP) in patients with decompensated heart failure (HF) and low output provided more effective treatment than inotropic agents in a small study.

Among adults with decompensated HF with no acute coronary syndrome (ACS), the IABP was significantly better than inotropic therapy at achieving a therapeutic target of 60% or higher mixed-venous oxygen saturation (SvO2), reported Corstiaan A. den Uil, MD, PhD, from Erasmus University Medical Center in Rotterdam, the Netherlands.

The IABP served as a bridge to transplantation or implantation of a left ventricular assist device (LVAD) in five patients, compared with no patients randomly assigned to inotropes as the initial therapy.

Dr Corstiaan den Uil

"This study highlights in my opinion an indication for a balloon pump usage that we may have forgotten in the last years due to publications that were negative, [reporting] complications of the balloon pump in myocardial infarction," he said here at the Congress of the European Association of Percutaneous Cardiovascular Interventions (EuroPCR) 2019.

Concurrent with den Uil's presentation, the study results were published online May 23 in the journal EuroIntervention.

To see whether early implantation of an IABP could improve on inotropes at increasing organ perfusion, den Uil and colleagues enrolled 32 adults with decompensated HF without ACS, systolic BP <100 mg Hg from low cardiac output (SvO2 <55%), and neutral or positive fluid balance despite being on high-dose intravenous diuretics.

Patients with moderate to severe aortic regurgitation, femoral artery occlusion, or ACS occurring with 7 days of enrollment were excluded.

All patients received a pulmonary artery catheter and were then randomly assigned to either primary 50 mL IABP implantation or treatment with intotropes (preferably enoximone, but dobutamine was also allowed).

The mean patient age was 53 years for patients assigned to IABP vs 61 years for those assigned to inotropes. The mean SvO2 was 40% and 46%, respectively.

The primary endpoint, the delta of SvO2 at 3 hours, was 17% with the IABP, compared with 5% with inotropes (P < .001).

Patients who received the balloon had significantly higher delta cardiac power output at 48 hours (+.027 vs +.09, P = .004); a higher percentage decline in N-terminal pro- brain type natriuretic peptide (NT-proBNP; -59.3% vs -16%, P < .001); larger drop in cumulative fluid balance (-3.066 mL vs -1.198 mL, P = .006), and a greater decline in the delta dyspnea score (-4 vs -2, P = .02).

Major adverse cardiac events (crossover or other escalation of therapy, death, heart failure hospitalization, transient ischemic attack, or stroke) were numerically but not significantly lower with IABP, occurring in 6 patients (38%) compared with 11 (69%) of those on inotropes.

Additionally, five patients in the IABP group vs none in the inotrope group were successfully bridged to LVAD or heart transplant (P = .04).

The numbers of patients with serious adverse events, in-hospital deaths, or deaths within 30 or 90 days of therapy were all lower in the IABP group, although the differences were not statistically significant given the small sample size, den Uil said.

Old Technology Keeps Patients Alive

"The balloon pump has been around for nearly 40 years, and I think in desperation we have not been clinically consistently impressed by the significant improvements with balloon pumps because they vary from patient to patient," commented panelist Tom Mabin, MD, from the Vergelegen Mediclinic in Franschoek, South Africa.

Asked by session comoderator Paula Mota, MD, from the William Harvey Hospital in Kent, UK, when in the course of care the decision to use the IABP is made, den Uil replied that before they started the trial his center first used inotropes and resorted to the balloon pump only when medications failed.

"I think this is one of the first reports demonstrating that maybe we should introduce mechanical support even before we start inotropes to improve the outcome. I'm not sure, because this is a very small trial, and we should test that in a multicenter trial next time," den Uil said.

In an interview with theheart.org | Medscape Cardiology, panelist Nick E. West, MD, from the Royal Papworth Hospital in Cambridge, UK, said that the IABP is still used in the UK in this population, largely because LVADs are not routinely reimbursed under the UK National Health Service.

"In the USA, the Impella [LVAD, Abiomed] is reimbursed. We have the Impella, the Impella is not reimbursed. That is a major problem since the Impella is definitely a better hemodynamic support device than the balloon pump," West said.

"Now, many of us use the balloon pump because it is readily available, it's relatively cheap, and it's quick to put in. The Impella, in contrast, leaves a much larger hole in the femoral artery, which can be an issue, and it's much more expensive," he added.

West noted that a third option, extracorporeal membrane oxygenation (ECMO) is "incredibly expensive, and incredibly invasive."

The study did not have external funding. Mabin and den Uil have disclosed no relevant financial relationships. Mota reported relationships with Abbott, Biosensors, Boston Scientific, Medtronic, St. Jude Medical, and Terumo. West reported unspecified conflicts.

Congress of the European Association of Percutaneous Cardiovascular Intervention (EuroPCR) 2019. Presented May 23, 2019.

EuroIntervention. Published online May 23, 2019. Abstract

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