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Intra-aortic balloon counterpulsation in cardiogenic shock: Is it really the end of an indication?

The lack of hard evidence to support the routine use of intra-aortic balloon counterpulsation (IABP) in cardiogenic shock has resulted in a class-IIIa recommendation in the newest European guidelines (1). Thus, its use is not only unsupported, but actively discouraged. A level-III recommendation indicates “ evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. ” Also, the evidence is judged to be based on “ multiple randomized clinical trials or meta-analyses. ” In our opinion, such a classifi cation of IABP in cardiogenic shock gives the IABP-SHOCK II trial too much impact, particularly considering the shortcomings of the trial and the positive observational support given for IABP in various other studies (2 – 5). A detailed discussion of whether this downgrading is supported by available data can be found in the online version and discussion of a much referred meta-analysis published in the European Heart Journal (4). Of particular interest, a similarly constructed meta-analysis (5) indicates that there are more positive merits to the IABP in cardiogenic shock than that suggested in the analysis from Sjauw et al. (4). In our highly specialized health care system with all therapeutic options available, a patient in cardiogenic shock still faces a 30-day mortality risk close to 50%. What is well known to primary care physicians, anesthesiologists, cardiologists, and cardiac surgeons alike is that time is everything when these patients are planned for transportation and treatment outside and inside the hospital. In the setting of shock, the timing of any modality to stabilize hemodynamics, including IABP, is highly relevant. The whole issue of timing has, however, been somewhat overshadowed by the neutral results from the IABP-SHOCK II trial (2,6). In this trial, only a minority (13%) of the patients received IABP before revascularization, and IABP was in reality used as an additional therapy to catecholamines in the vast majority of patients (90%). Some would argue that this may preclude the potential benefi ts of mechanical circulatory support, such as reducing the need for inotropes/vasopressors and stabilizing the patient through complex revascularization procedures. Could the results from IABP-SHOCK II have been different if, per protocol, IABP was inserted before percutaneous coronary intervention (PCI)? The aspect of timing has been observed in coronary surgery. In a meta-analysis, seven papers including approximately 300 patients were included (3). These small-number studies demonstrated a benefi cial effect of preoperative IABP on mortality, low-output failure, and length of stay in ICU. Thus, in this setting of an alternate revascularization procedure, a preprocedural IABP seems to be of preference. Interestingly, the randomized balloon pump-assisted coronary intervention study (BCIS-1) on prophylactic use of IABP during high-risk PCI showed improved outcomes in the long-term analysis with a 34% relative reduction in all-cause mortality (7). The authors discuss whether this effect could be due to less periprocedural ischemia and/or a more aggressive (and extensive) revascularization in patients on hemodynamic support, but the mechanisms behind Scandinavian Cardiovascular Journal, 2014; 48: 325–327