Can High Risk Cardiac Surgery Save the Intra-Aortic Balloon Pump?

Ed Litton - Intensivist Royal Perth HospitalSMACC 13 March 2013

Peer review monster by Gideon Burton @ Flickr (CC)

Kantrowitz et al, Initial clinical experience with intra-aortic balloon pumping in cardiogenic shock. JAMA 1968; 203:135-140

Doing something, technical, and with eloquent physiology…

Lewis et al Australasian Trends in IABP Weaning. Critical Care & Resuscitation 2006 8:361-367Prodzinsky et al Hemodynamic Effects of IABC in Patients with AMI Complicated by Cardiogenic Shock SHOCK 2012 37:4;378-384

The IABP-Shock II Trial

• Validity:– Blinding, Effect size, Crossover

• Generalisability:– Time to Treatment Initiation, Baseline Mortality/Subgroups

• Glass Half Full…

Thiele et al Intraaortic balloon support for myocardial infarction with cardiogenic shock (IABP Shock II) 2012 NEJM 367:14 1287-96

www.who.int/nmh/en/

CABG Trends

Epstein, AJ et al Coronary Revascularization trends in the United States, 2001 – 2008 JAMA 2011; 305(17); 1769-1776Velazquez et al, Coronary Artery Bypass Surgery in Patients with Left Ventricular Dysfunction 2011 NEJM 364;1607-16

- CABG for:- Low ejection fraction- Left main- Triple vessel disease- Diabetics

Evidence for IABP in Cardiac Surgery

• Limitations:– Small numbers, single centre, treatment vs prophylaxis

Theologou et al Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting 2011 Cochrane Database of Systematic Reviews

Defining High Risk and ANZ Outcomes

• ANZ single centre high risk mortality with IABP Hazard ratio 0.47 (CI 0.26-0.84)

• National database 15% of High Risk Patients Currently Receive Preoperative IABP

Litton et al Preoperative Intra-aortic balloon pump in high-risk CABG 2012 ACTA 20;146-152Litton et al Current use of IABP in high risk cardiac surgery 2008 Critical Care & Resuscitation 10;188-192

Prophylactic INtra-aortic BALLoon Counterpulsation in High-Risk Cardiac Surgery

• Multicentre prospective observational study of high risk cardiac surgery– Describe current management strategies and outcomes– Estimate treatment effect– Determine RCT feasibility and design

• Coinvestigators: Frances Bass, Dhenisha Dahya

(PM), Anthony Delaney, Graham Hillis, Ed Litton, Silvana Marasco, Shay McGuinness, Dan Mullany, Paul Myles, Chris Reid, Julian Smith

• Sites:– Auckland City Hospital– Prince Charles Hospital– North Shore Private

Hospital– Mount Hospital– Royal North Shore Hospital– Royal Perth Hospital– The Alfred Hospital– Wellington General

Hospital

If Interested Contact: ed_litton@hotmail.com or Dhenisha.dahya@monash.edu