When is balloon pump (Intra-Aortic Balloon Pump, IABP) augmentation indicated?

Indications for Intra-Aortic Balloon Pump (IABP) Augmentation

The intra-aortic balloon pump (IABP) is primarily indicated for specific acute mechanical complications of myocardial infarction, severe acute myocarditis, and as a bridge to more definitive therapies in selected patients, but is no longer routinely recommended for cardiogenic shock complicating acute myocardial infarction.

Primary Indications for IABP

• Mechanical complications of acute myocardial infarction requiring circulatory support before surgical correction, including:

  • Interventricular septal rupture 1
  • Acute mitral regurgitation due to papillary muscle rupture 1, 2
  • Free wall rupture with tamponade 1

• Severe acute myocarditis with hemodynamic compromise 1

• Bridge therapy for patients awaiting:

  • Ventricular assist device implantation 1
  • Heart transplantation 1, 3

• Selected patients with acute myocardial ischemia or infarction before, during, and after percutaneous or surgical revascularization who are at high risk for complications 1

Not Routinely Recommended

• Cardiogenic shock complicating acute myocardial infarction - The IABP-SHOCK II trial showed no mortality benefit of IABP in this setting 1

• Routine use in high-risk STEMI patients - Meta-analyses of randomized trials do not support this practice 1

• Other causes of cardiogenic shock not related to mechanical complications or myocarditis 1

Decision Algorithm for IABP Use

1. Assess for specific indications:

   • Is there a mechanical complication of MI (VSR, acute MR, free wall rupture)? → Consider IABP 1, 2
   • Is there severe acute myocarditis with hemodynamic compromise? → Consider IABP 1
   • Is the patient awaiting VAD or heart transplantation? → Consider IABP 1, 3

2. Evaluate hemodynamic status:

   • Systolic BP <85 mmHg or shock not responding to initial therapy → Consider IABP if mechanical complication present 1
   • Evidence of hypoperfusion (cold skin, low pulse volume, poor urine output, confusion) → Consider IABP if mechanical complication present 1

3. Check for contraindications:

   • Severe peripheral vascular disease 4
   • Aortic regurgitation 4
   • Aortic dissection (relative contraindication - may be used cautiously in post-surgical cases) 4, 5
   • Aortic aneurysm 4

Important Considerations

• IABP insertion should be considered in patients with hemodynamic instability/cardiogenic shock due to mechanical complications of MI 1

• For patients with cardiogenic shock complicating acute myocardial infarction without mechanical complications, the evidence does not support routine IABP use 1

• IABP may be considered as a bridge to surgery in patients with mechanical complications of MI, particularly those with cardiogenic shock, as it significantly reduces preoperative mortality (11% vs 88%) 2

• The benefit-risk ratio must be carefully evaluated, as IABP use carries risks of complications including bleeding, systemic thromboembolism, limb ischemia, and rarely death 4, 6

• When used for weaning from cardiopulmonary bypass, IABP has shown a 75% success rate, with 35% of these patients surviving to hospital discharge 6

• For patients with acute-on-chronic heart failure complicated by cardiogenic shock, IABP may have a physiological rationale but requires further study 3

Placement Considerations

• Insertion through the ascending aorta intraoperatively has significantly fewer complications (4%) compared to femoral or iliac artery approach (25%) 6

• Risk of IABP-related spinal cord paralysis is approximately 1.7% 6

• Duration of IABP therapy is typically short (average 3-4 days) 5