When is mechanical support, such as an intra-aortic balloon pump (IABP), recommended for patients undergoing percutaneous coronary intervention (PCI) for stable ischemic heart disease?

Mechanical Support for PCI in Stable Ischemic Heart Disease

Routine prophylactic mechanical support is NOT recommended for stable ischemic heart disease patients undergoing PCI, but may be reasonable in highly selected high-risk cases to prevent hemodynamic compromise. 1

Guideline Recommendations

The 2021 ACC/AHA/SCAI guidelines provide a Class 2b recommendation (Level of Evidence B-R) for elective insertion of hemodynamic support devices as an adjunct to PCI in selected high-risk patients. 1 This weak recommendation reflects that:

• Routine use of hemodynamic support devices for complex PCI has NOT been shown to reduce cardiovascular events 1
• The BCIS-1 trial showed no difference in the primary composite outcome of death, MI, cerebrovascular event, or repeat revascularization with IABP support 1
• The PROTECT II trial comparing Impella versus IABP for high-risk PCI was halted for futility after showing no benefit in major adverse cardiac events 1

When to Consider Mechanical Support

Mechanical support may be reasonable in the following high-risk scenarios: 1

• Severe left ventricular dysfunction (LVEF ≤25-30%) with complex multivessel disease 1
• Left main stenosis >50% requiring intervention 1
• Last remaining patent conduit to viable myocardium 1
• Single target lesion jeopardizing ≥50% of remaining viable myocardium 1
• Three-vessel disease unprotected by prior bypass surgery requiring complex intervention 1

Device Selection Considerations

IABP Characteristics 1

• Provides minimal hemodynamic support but improves coronary and cerebral perfusion
• Advantages: ease of use, smaller catheter diameter, lower vascular complication rates
• Limited in severe peripheral artery disease or aortic disease
• Contraindicated in severe aortic insufficiency 2

Impella Characteristics 1, 3

• Provides greater left ventricular support than IABP (2.5-5.0 L/min depending on model)
• More complex insertion but superior hemodynamic augmentation
• Contraindicated in left ventricular thrombus, aortic stenosis, severe peripheral artery disease, or aortic disease 1, 3
• Higher rates of bleeding (8.5% vs 3.0%) and vascular complications (9.8% vs 3.8%) compared to IABP 3

Critical Evidence Limitations

Observational studies have challenged the efficacy, safety, and cost-effectiveness of routine hemodynamic support devices. 1 Despite theoretical hemodynamic benefits:

• No mortality reduction has been demonstrated in randomized trials for elective high-risk PCI 1
• Meta-analyses show no improvement in left ventricular ejection fraction with prophylactic support 1
• Increased procedural complications, particularly hypotension with IABP 1

Clinical Algorithm for Decision-Making

For stable ischemic heart disease patients undergoing PCI: 1

1. Assess patient risk factors:

   • LVEF <30%, decompensated heart failure (Killip Class 3), chronic kidney disease (creatinine >2.0 mg/dL), serious ventricular arrhythmias 1

2. Assess lesion complexity:

   • Left main disease, three-vessel disease, diffuse disease >20mm, extreme angulation >90°, heavy calcification, inability to protect major side branches 1

3. If BOTH high patient risk AND high lesion complexity:

   • Consider prophylactic support device insertion before starting PCI 1
   • Choose Impella over IABP if greater hemodynamic support anticipated and no contraindications exist 1, 3

4. If only moderate risk:

   • Proceed without prophylactic support but have device readily available 1

Important Caveats

• This recommendation applies ONLY to stable ischemic heart disease, NOT acute coronary syndromes or cardiogenic shock 1
• The decision should weigh the lack of proven mortality benefit against potential complications including bleeding, vascular injury, and increased costs 1, 3
• Prophylactic support showed better outcomes than rescue support in observational data (8% vs 29% mortality at 6 months), suggesting if used, insertion should occur before rather than after complications develop 4
• Extracorporeal membrane oxygenation and TandemHeart devices are rarely used for elective PCI support 1