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Intra-Aortic Balloon Pump for Left Ventricular Unloading in VA-ECMO: Timing is Everything

An editorial published in April 2022 discusses the benefits and pitfalls of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) combined with intra-aortic balloon pumps (IABP) to manage CS.

An editorial published in April 2022 discusses the benefits and pitfalls of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) combined with intra-aortic balloon pumps (IABP) to manage CS. The complete manuscript, written by Agam Bansal, Dhiran Verghese, and Sarachandra Vallabhajosyula, can be found in the Journal of the American Heart Association. A summary of the editorial is detailed below.

Cardiogenic shock (CS) is one of the leading causes of in-hospital mortality, second only to acute myocardial infarction (AMI). Reports conclude that between 40,000 and 50,000 individuals are affected by CS in the United States each year. Despite advances in critical cardiovascular care, the 30-day mortality for patients with AMI-CS still lingers around 40%.

Despite the ability of VA-ECMO to offer high cardiac output with biventricular and respiratory support, one of its most significant limitations is retrograde aortic flow and the resulting increase in afterload. For those with CS, this increase in afterload can be harmful.

The intro-aortic balloon pump is a type of mechanical circulatory support. Additionally, it is the most commonly used device for left ventricle decompression because of its ease of insertion and maintenance, among other favorable qualities.

Bansal et al. detail an article by Nisha et al. which utilized a cohort of 3815 patients with AMI-CS who underwent primary percutaneous coronary intervention. The patient population was split into categories of VA-ECMO+IAPB (2964 patients) and VA-ECMO alone (851 patients).

Despite the younger average age of patients who had VA-ECMI+IABP, they were also more likely to have higher comorbidity rates, including dyslipidemia, hypertension, atrial fabulation, and diabetes. Even though comorbidities were higher, the study's authors concluded that patients with VA-ECMO+ IABP showed significantly lower in-hospital, 7-day, and 30-day mortality.

The study also found that patients who were started on IABP followed by VA-ECMO experienced the highest mortalities compared to all other treatment types and orders, such as VA-ECMO followed by IABP and VA-ECMO+IABP on the same day. This information plays a vital role in guiding the best order for treatment.

Unknowns still exist regarding the benefits of IABP, such as the timing of unloading the LV with IABP in AMI-CS patients on VA-ECMO. Bansal et al. emphasize that further studies are required to understand these qualities.

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Find Bansal et al.'s complete manuscript in the Journal of the American Heart Association for further reading.
 

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