1119 INTRA-AORTIC BALLOON PUMP AS BRIDGE TO HEART REPLACEMENT THERAPY IN CARDIOGENIC SHOCK COMPLICATING CHRONIC HEART FAILURE
Authors: Sabatino Mario , Marcelli Chiara , Napolitano Fiorenza Pia , Giovannelli Giada , Masetti Marco , Spitaleri Giosafat , Corsini Anna , Suarez Sofia Martin , Galiè Nazzareno , Potena Luciano 
Published: December 2022

Abstract

Background
Temporary mechanical circulatory support (MCS) could provide stabilization and improve prognosis in selected patients with cardiogenic shock (CS). Intra-aortic balloon pump (IABP) is a common percutaneous MCS device, characterized by wide availability, easy deployment and low complication rate. Despite its use in CS caused by acute myocardial infarction has been discouraged based on available evidence, recent data have renewed the interest in IABP as bridge to heart replacement therapy (HRT; heart transplantation or durable LVAD implant) in patients with cardiogenic shock complicating acutely decompensated chronic heart failure. We sought to review our experience with IABP support in this population eligible for HRT at a large-volume transplant center.

Methods
We retrospectively reviewed all adult patients (&gt; 18 years old) who received IABP at our center between 2016 and 2021. We included patients with chronic heart failure with reduced ejection fraction (LVEF &lt; 40% for at least 3 months) eligible for heart replacement therapy (i.e. &lt; 70 years old). Primary endpoint was IABP success defined as weaning to discharge or successful bridge to HRT without need for MCS escalation. In addition, in-hospital mortality without HRT and MCS complications were assessed.

Results
Study population consisted of 49 patients with mean age of 54±9 years, 84% of whom were male. Etiology was non-ischemic dilated cardiomyopathy in 72% of patients and mean LVEF was 19±5%. 12 patients (24%) were already listed for heart transplantation. 26 patients (53%) developed cardiogenic shock during hospitalization for acutely decompensated heart failure, while the others presented CS upon admission. IABP success was achieved in 32 (65%) of patients, of whom 13 (39%) were bridged to heart transplantation, 6 (18%) to durable LVAD, while 13 (43%) were weaned from support and discharged. 11 patients (22%) died without MCS upgrade or HRT, including one death occurring 18 days after IABP weaning. 6 patients (12%) required escalation of mechanical circulatory support: 5 with extracorporeal membrane oxygenator (ECMO), 2 of whom were transplanted, and 1 with axillary-implanted Impella 5.0 as effective bridge to durable LVAD. In-hospital mortality without HRT was 28%. Median duration of IABP support was 8 days (0-107). 66% of patients were treated with at least one and 12% with two or more inotropes. Complications occurred in 4 (9%) patients in IABP group, including 3 cases of limb ischemia without sequelae and one fatal bleeding not related to insertion site. Ischemic and bleeding complications were found in 4 out of 5 ECMO-supported patients. Among demographic and laboratory characteristics assessed at baseline and after 24 hours from shock, persistence of increased lactates (&gt;2 mmol/l) at 24 hours and number of inotropic drugs were independently associated with both IABP failure and mortality.

Conclusions
In patients with cardiogenic shock complicating chronic heart failure, IABP appears a safe and effective bridge strategy to heart replacement therapy with favorable outcomes and acceptable complication rates. Persistence of markers of hypoperfusion and increased need for cardioactive drugs are associated with worse outcomes and should trigger evaluation for MCS escalation. More studies are needed to fully characterize the role and timing of IABP support in this clinical scenario.