Cardiogenic shock in the setting of severe aortic stenosis: role of intra-aortic balloon pump support
ABSTRACT To investigate the haemodynamic effects of intra-aortic balloon pump (IABP) support in patients with severe aortic stenosis (AS) presenting in cardiogenic shock (CS).
Observational cohort study. Setting Tertiary academic centre coronary intensive care unit (CICU). Patients Patients presenting to the CICU in CS with an established diagnosis of AS (n=25 with mean age (± SD) of 73.5 ± 9.5 years). The peak and mean Doppler AV gradients were 67 ± 26.8 mm Hg and 39.8 ± 16.8 mm Hg, respectively, with a mean baseline cardiac index of 1.77 ± 0.38 l/min/m²). Interventions Utilisation of IABP. Main outcome measures Haemodynamic impact of IABP over time.
With the insertion of an IABP, patients' cardiac index improved from 1.77 l/min/m² to 2.18 and 2.36 l/min/m² at 6 and 24 h, respectively (p<0.001 for both times points). Systemic vascular resistance was reduced from 1331 dyn/s/cm⁵ to 1265 and 1051 dyn/s/cm⁵ at 6 and 24 h, respectively (p=0.66 and p=0.005, respectively). The central venous pressure was reduced from 14.8 mm Hg to 13.2 and 10.9 mm Hg at 6 and 24 h, respectively (p=0.12 and p=0.03, respectively). IABP insertion was associated with a complication in 3 of the 25 cases, including a deep vein thrombosis, thrombocytopenia, limb ischaemia, and technical malfunctioning of the device.
IABP support improves the haemodynamic profile in patients with severe AS who present in CS. IABP utilisation in this critically ill population should be strongly considered as patients are being evaluated for candidacy for advanced interventions.
SourceAvailable from: Leonard E Braitman[Show abstract] [Hide abstract]
ABSTRACT: BACKGROUND: Comorbid aortic stenosis (AS) has been considered a precaution when applying enhanced external counterpulsation (EECP) to individuals with angina due to concerns about treatment-related hemodynamic changes. HYPOTHESIS: The aim of this study was to determine whether EECP safely reduces symptoms of myocardial ischemia and improves hemodynamics in individuals with AS. METHODS: Forty-three patients with AS (average age, 73 years; 86% male) and 43 comparison patients without AS were chosen from a database of 1327 EECP patients. Canadian Cardiovascular Society (CCS) Functional Angina Classification, diastolic augmentation ratio, and blood pressure were measured at baseline and on completion of the course of EECP. RESULTS: Thirty-five of the 43 patients with AS (81%, 95% CI: 66.6% to 91.6%) and 38 of the 43 without AS (88%, 95% CI: 74.9% to 96.1%) improved in angina class (P < 0.0001). There was no statistical difference between the percentages in patients with and without AS (P = 0.54). CCS angina class outcome was not associated with AS severity (P = 0.55). The percentage of patients with diastolic augmentation ratio ≥1.0 was 16.3% in both groups at baseline and improved to 39.5% in AS patients and 37.2% in non-AS patients after EECP (both P = 0.002). The average decreases in systolic blood pressure in subjects with AS (-15 mm Hg, 95% CI: 11 to 20, P < 0.0001) and without AS (-18 mm Hg, 95% CI: 14 to 22, P < 0.0001) were similar (P = 0.31). No major adverse cardiac events were reported. CONCLUSIONS: Angina patients with AS who undergo EECP had clinically important symptomatic and hemodynamic improvements comparable to their non-AS counterparts. Clin. Cardiol. 2012 doi: 10.1002/clc.22073 The authors have no funding, financial relationships, or conflicts of interest to disclose.Clinical Cardiology 02/2013; 36(2). DOI:10.1002/clc.22073 · 2.23 Impact Factor
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