1. IABP
Houghton 3/6/2014

2. Disclosure’s
• I don’t like IABP’s

3. Am J Cardiology Review Article (2006) – great for general principles, complications, indications

4. Indications ?
?? Cardiogenic shock (left ventricular failure or mechanical complications of
an acute myocardial infarction)
? Intractable angina
● Low cardiac output after cardiopulmonary bypass
?? Adjunctive therapy in high risk or complicated angioplasty
?? Prophylaxis in patients with severe left main coronary arterial stenosis in
whom surgery is pending
? Intractable myocardial ischemia awaiting further therapy
● Refractory heart failure as a bridge to further therapy
● Intractable ventricular arrhythmias as a bridge to further therapy.
AHA Class IIa -2004 The use of prophylactic intra-aortic balloon pump as an
adjunct to myocardial protection is probably indicated in patients with
evidence of ongoing myocardial ischemia and/or patients with a subnormal
cardiac index. (Level of Evidence: B)

5. Prophylactic use of intra-aortic ballon pump in
aortocoronary bypass for patients with left main
coronary artery disease.
• Ann Surg. 1978 Feb;187(2):118-21.
• Patients: 20 patients with LM stenosis >50%, 50%
patients unstable angina
• Results: 0 patients died, 1 had postoperative MI
• Conclusions: “Prophylactic intra-aortic balloon
pumping is a low risk procedure that should be
utilized routinely in aortocoronary bypass surgery for
left main coronary artery disease”

6. A Randomized Controlled Trial of Preoperative Intra-Aortic
Balloon Pump in Coronary Patients With Poor Left Ventricular
Function Undergoing Coronary Artery Bypass Surgery
• Critical Care Medicine 2013 PMID: 23921278
• Patients: 110, LVEF (< 35%), HD stable
• Methods: IABP placed immediately preoperatively
• Results: No difference in 30 day mortality, IABP required less
intraoperative dopamine

7. Elective intra-aortic balloon counterpulsation during
high-risk percutaneous coronary intervention: a
randomized controlled trial (BCIS-1)
• JAMA. 2010 PMID 20736470
• Patients: 301 with LVEF <30%, severe CAD (by
jeopardy score)
• Methods: prophylactic IABP prior to PCI vs none
• Results: No difference in MACCE at discharge, No
difference in all-cause mortality at 6 months

8. Long-term mortality data from the balloon pump-assisted
coronary intervention study (BCIS-1): a randomized, controlled
trial of elective balloon counterpulsation during high-risk
percutaneous coronary intervention.
• Circulation 2013 PMID 23224207
• Patients: 301 with LVEF <30%, severe CAD (by jeopardy score)
• Methods: prophylactic IABP prior to PCI vs none
• Results: All-cause mortality at 51 months was 33% in the
overall cohort, with significantly fewer deaths occurring in the
elective IABP group (n=42) than in the group that underwent
PCI without planned IABP support (n=58) (hazard ratio, 0.66;
95% confidence interval, 0.44-0.98; P=0.039)

9. Intra-aortic balloon pump counterpulsation (IABP) for
myocardial infarction complicated by cardiogenic shock
• Cochrane Database Syst Rev. 2011 PMID: 21735410
• Criteria: Randomized controlled trials on patients with
myocardial infarction complicated by cardiogenic shock.
• Results: Data from a total of 190 patients with acute
myocardial infarction and cardiogenic shock were included in
the meta-analysis
– HR's for all-cause 30-day mortality of 1.04 (95% CI 0.62 to
1.73) provides no evidence for a survival benefit.

10. Intraaortic balloon support for myocardial
infarction with cardiogenic shock. (IABP-SHOCK)
• N Engl J Med 2012 PMID 22920912
• Patients: 600 patients with cardiogenic shock
complicating acute myocardial infarction
• Results: IABP did not significantly reduce 30-day
mortality in patients with cardiogenic shock
complicating acute myocardial infarction for whom
an early revascularization strategy was planned, no
differences in secondary outcomes

11. Fun Facts
• In non-heparinized experimental animals, an immobile,
deflated balloon is subject to thrombosis within 20 minutes
• The largest IABP device manufacturer recommends that an
immobile IABP device be removed within 30 minutes
• The most commonly used triggers are (1) the
electrocardiographic (ECG) waveform and (2) the systemic
arterial pressure waveform
• Helium gas is used inside balloon b/c it facilitates rapid
transmission from console to balloon

12. Where is the IABP?

14. Conclusion
• I don’t like IABP’s
• Multiple RCT’s within past 5 years regarding
IABP’s
• Many demonstrating lack of convincing evidence
for its use depending on precise indication
• AHA Guidelines are out of date in light of recent
paper’s and not mentioned in most recent
guidelines
– 2011 ACCF/AHA Guideline for CABG
– ACC/AHA 2004 Guidelines for CABG