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Wang W, Yang F, Lin X, Zhong Q, Li Z, Chen X, Wang J, He K. The Preference, Effect, and Prognosis of Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock Patients: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6656926. [PMID: 33542922 PMCID: PMC7840249 DOI: 10.1155/2021/6656926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUNDS Intra-aortic balloon counterpulsation is increasingly used in acute myocardial infarction complicated by cardiogenic shock. The aim of this study was to explore the preference, effect, and prognosis of intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock patients. METHODS Data of acute myocardial infarction complicated by cardiogenic shock patients at the Fourth Medical Center of PLA General Hospital were collected retrospectively. A propensity score was calculated with a logistic regression which contained clinically meaningful variables and variables selected by Lasso and then used to match the control group. The cumulative incidence curve and Gray's test were employed to analyse the effect and prognosis of intra-aortic balloon counterpulsation on mortality. RESULTS A total of 1962 acute myocardial infarction cases admitted between May 2015 and November 2018 were identified, and 223 cases with acute myocardial infarction complicated by cardiogenic shock were included as the study cohort, which contained 34 cases that received IABP and 189 cases that did not receive IABP. Patients with higher alanine aminotransferase (OR = 1.93, 95% CI 1.29-2.98), higher triglyceride (OR = 3.71, 95% CI 1.87-7.95), and higher blood glucose (OR = 1.08, 95% CI 0.99-1.18) had a higher probability of receiving intra-aortic balloon counterpulsation. In the propensity score matching analysis, 34 cases received intra-aortic balloon counterpulsation and 102 matched controls were included in the comparison. By comparing the cumulative incidence of in-hospital mortality, there was no statistically significant difference between the intra-aortic balloon counterpulsation group and matched control group (P = 0.454). CONCLUSION The use of intra-aortic balloon counterpulsation may not improve the prognosis of the acute myocardial infarction complicated by cardiogenic shock patients.
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Affiliation(s)
- Wenjun Wang
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Feifei Yang
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xixiang Lin
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qin Zhong
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zongren Li
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xu Chen
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 CG Utrecht, Netherlands
| | - Kunlun He
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
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Alternate Approach to Concomitant Carotid and Coronary Disease: Perioperative IABP Use during Carotid Endarterectomy. Ann Vasc Surg 2020; 72:663.e9-663.e13. [PMID: 33285271 DOI: 10.1016/j.avsg.2020.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/20/2020] [Accepted: 10/01/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Demographics are shifting toward an increasingly older population in the United States; thus, it is imperative that patients with a complex cardiovascular history are approached in a systematic fashion. Currently, there is no clear protocol on how best to manage elderly patients who present with both severe coronary artery disease and symptomatic carotid stenosis. For cardiac patients with severe, asymptomatic, high-grade carotid artery stenosis, there may be even more of a conundrum. Although most centers would tend to manage the asymptomatic carotid stenosis expectantly, it is well known that patients with severe, uncorrected internal carotid artery disease are at an increased risk of experiencing a cerebrovascular accident during coronary artery bypass grafting (CABG). One approach that has been recognized in other settings as a cost-effective strategy to stabilize high-risk elderly patients preoperatively is the use of an intra-aortic balloon pump (IABP). To better understand the best approach to take in these patients with concomitant disease, we analyzed the outcomes of 4 patients who underwent placement of an IABP before carotid endarterectomy (CEA) as a bridge to CABG. METHODS Between 2017 and 2019, 4 patients presented with multivessel symptomatic coronary artery disease and greater than 90% stenosis of at least one internal carotid artery and underwent either staged or simultaneous CEA and CABG. There was placement of an IABP in all patients before the CEA. Time to CABG ranged from a simultaneous procedure to 23 days after CEA. RESULTS The only death within 30-day postoperation involved the patient who had CEA and CABG performed simultaneously. None of the surviving patients experienced a myocardial infarction. Two of the 4 patients experienced acute kidney injury after surgery, and one patient developed atrial fibrillation postoperatively. None of the patients experienced a postoperative neurological complication. In addition, there were no access site complications associated with IABP placement. CONCLUSIONS A staged procedure with placement of an IABP can be successfully used in carefully selected patients presenting with concomitant severe carotid and coronary artery disease who will undergo surgical management of their disease. The stabilization provided by IABP was potentially protective against adverse postoperative events and appeared to allow for flexibility in the time between CEA to CABG for patients. Additional studies are necessary to further understand the impact of such an approach.
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Özen Y, Aksut M, Cekmecelioglu D, Dedemoglu M, Altas O, Sarikaya S, Rabus MB, Kirali K. Intra-aortic balloon pump experience: a single center study comparing with and without sheath insertion. J Cardiovasc Thorac Res 2018; 10:144-148. [PMID: 30386534 PMCID: PMC6203873 DOI: 10.15171/jcvtr.2018.23] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/31/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction: The mechanical circulation support used in treatment of low cardiac output at most
is the intra-aortic balloon pump (IABP). Its usage fields are the complications occurring due to
ischemic heart disease, disrupted left ventricle function, and the low cardiac output syndrome
occurring during coronary artery by-pass surgery.
Methods: During 28 years from 1985 to 2013, IABP support has been implemented to 3135 patients
in our cardiac surgery operating theater and intensive care unit. The mean age of the patients was
61.4 ± 13.2 years (16-82). 2506 patients (80%) were the ones whom the cardiac surgery has been
implemented. IABP support has been provided for 629 (20%) patients for medical treatment. We
utilized IABP most frequently in coronary artery patients (70%). The first choice for placing the
balloon catheter is the femoral artery in 3093 cases (98.7%).
Results: The most frequently observed balloon complication was the lower extremity ischemia in
383 cases (12.2%).The leg ischemia was statistically significantly more frequent in patients with
sheath (P=0.004). The extremity ischemia has developed in 4 of 12 patients with balloon placed
from upper extremity. The local bleeding and balloon rupture were more frequent in patients
whom the balloon has been placed without sheath. The mortality due to IABP has occurred in
only 5 patients.
Conclusion: Despite increase in IABP usage frequency rapidly, the complications due to catheter
are still seen. We believe that the leg ischemia that is the most frequently seen complication can
be prevented via IABP use without sheath.
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Affiliation(s)
- Yücel Özen
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Mehmet Aksut
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Davut Cekmecelioglu
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Mehmet Dedemoglu
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Ozge Altas
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Sabit Sarikaya
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Murat Bulent Rabus
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Kaan Kirali
- Kartal Kosuyolu Heart Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
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Unverzagt S, Buerke M, de Waha A, Haerting J, Pietzner D, Seyfarth M, Thiele H, Werdan K, Zeymer U, Prondzinsky R. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev 2015; 2015:CD007398. [PMID: 25812932 PMCID: PMC8454261 DOI: 10.1002/14651858.cd007398.pub3] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intra-aortic balloon pump counterpulsation (IABP) is currently the most commonly used mechanical assist device for patients with cardiogenic shock due to acute myocardial infarction. Although there has been only limited evidence from randomised controlled trials, the previous guidelines of the American Heart Association/American College of Cardiology (AHA/ACC) and the European Society of Cardiology (ESC) strongly recommended the use of the IABP in patients with infarction-related cardiogenic shock on the basis of pathophysiological considerations, non-randomised trials and registry data. The recent guidelines downgraded the recommendation based on a meta-analysis which could only include non-randomised trials showing conflicting results. Up to now, there have been no guideline recommendations and no actual meta-analysis including the results of the large randomised multicentre IABP-SHOCK II Trial which showed no survival benefit with IABP support. This systematic review is an update of the review published in 2011. OBJECTIVES To evaluate, in terms of efficacy and safety, the effect of IABP versus non-IABP or other assist devices guideline compliant standard therapy on mortality and morbidity in patients with acute myocardial infarction complicated by cardiogenic shock. SEARCH METHODS Searches of CENTRAL, MEDLINE (Ovid) and EMBASE (Ovid), LILACS, IndMed and KoreaMed, registers of ongoing trials and proceedings of conferences were updated in October 2013. Reference lists were scanned and experts in the field contacted to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials on patients with acute myocardial infarction complicated by cardiogenic shock. DATA COLLECTION AND ANALYSIS Data collection and analysis were performed according to the published protocol. Individual patient data were provided for six trials and merged with aggregate data. Summary statistics for the primary endpoints were hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS Seven eligible studies were identified from a total of 2314 references. One new study with 600 patients was added to the original review. Four trials compared IABP to standard treatment and three to other percutaneous left assist devices (LVAD). Data from a total of 790 patients with acute myocardial infarction and cardiogenic shock were included in the updated meta-analysis: 406 patients were treated with IABP and 384 patients served as controls; 339 patients were treated without assisting devices and 45 patients with other LVAD. The HR for all-cause 30-day mortality of 0.95 (95% CI 0.76 to 1.19) provided no evidence for a survival benefit. Different non-fatal cardiovascular events were reported in five trials. During hospitalisation, 11 and 4 out of 364 patients from the intervention groups suffered from reinfarction or stroke, respectively. Altogether 5 out of 363 patients from the control group suffered from reinfarction or stroke. Reocclusion was treated with subsequent re-revascularization in 6 out of 352 patients from the intervention group and 13 out of 353 patients of the control group. The high incidence of complications such as moderate and severe bleeding or infection in the control groups has to be attributed to interventions with other LVAD. Possible reasons for bias were more frequent in small studies with high cross-over rates, early stopping and the inclusion of patients with IABP at randomisation. AUTHORS' CONCLUSIONS Available evidence suggests that IABP may have a beneficial effect on some haemodynamic parameters. However, this did not result in survival benefits so there is no convincing randomised data to support the use of IABP in infarct-related cardiogenic shock.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburge Straße 8, Halle/Saale, Germany, 06097
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Unverzagt S, Machemer MT, Solms A, Thiele H, Burkhoff D, Seyfarth M, de Waha A, Ohman EM, Buerke M, Haerting J, Werdan K, Prondzinsky R. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev 2011:CD007398. [PMID: 21735410 DOI: 10.1002/14651858.cd007398.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intra-aortic balloon pump counterpulsation (IABP) is currently the most commonly used mechanical assist device for patients with cardiogenic shock due to acute myocardial infarction.Although there is only limited evidence by randomised controlled trials, the current guidelines of the American Heart Association/American College of Cardiology and the European Society of Cardiology strongly recommend the use of the intra-aortic balloon counterpulsation in patients with infarction-related cardiogenic shock on the basis of pathophysiological considerations as also non-randomised trials and registry data. OBJECTIVES To determine the effect of IABP versus non-IABP or other assist devices guideline compliant standard therapy, in terms of efficacy and safety, on mortality and morbidity in patients with acute myocardial infarction complicated by cardiogenic shock. SEARCH STRATEGY Searches of CENTRAL, MEDLINE and EMBASE, LILACS, IndMed and KoreaMed, registers of ongoing trials and proceedings of conferences were conducted in January 2010, unrestricted by date. Reference lists were scanned and experts in the field contacted to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials on patients with myocardial infarction complicated by cardiogenic shock. DATA COLLECTION AND ANALYSIS Data collection and analysis were performed according to a published protocol. Individual patient data were provided for five trials and merged with aggregate data. Summary statistics for the primary endpoints were hazard ratios (HR's) and odds ratios with 95% confidence intervals (CI). MAIN RESULTS Six eligible and two ongoing studies were identified from a total of 1410 references. Three compared IABP to standard treatment and three to percutaneous left assist devices (LVAD). Data from a total of 190 patients with acute myocardial infarction and cardiogenic shock were included in the meta-analysis: 105 patients were treated with IABP and 85 patients served as controls. 40 patients were treated without assisting devices and 45 patients with LVAD. HR's for all-cause 30-day mortality of 1.04 (95% CI 0.62 to 1.73) provides no evidence for a survival benefit. While differences in survival were comparable in patients treated with IABP, with and without LVAD, haemodynamics and incidences of device related complications show heterogeneous results. AUTHORS' CONCLUSIONS Available evidence suggests that IABP may have a beneficial effect on the haemodynamics, however there is no convincing randomised data to support the use of IABP in infarct related cardiogenic shock.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburge Straße 8, Halle/Saale, Germany, 06097
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Lavana JD, Fraser JF, Smith SE, Drake L, Tesar P, Mullany DV. Influence of timing of intraaortic balloon placement in cardiac surgical patients. J Thorac Cardiovasc Surg 2010; 140:80-5. [DOI: 10.1016/j.jtcvs.2009.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 08/20/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
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Boeken U, Feindt P, Schurr P, Lichtenberg A. Mechanische Herz-Kreislauf-Unterstützung mittels intraaortaler Ballongegenpulsation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-009-0754-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sistino JJ. Using decision-analysis and meta-analysis to predict coronary artery bypass surgical outcomes – a model for comparing off-pump surgery to miniaturized cardiopulmonary bypass circuits. Perfusion 2008; 23:255-60. [DOI: 10.1177/0267659109104146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Coronary artery bypass (CABG) surgery with cardiopulmonary bypass (CPB) has been the “gold standard” for many years. However, methods to conduct off-pump coronary artery bypass (OPCAB) surgery with a beating heart have decreased the use of CPB. Improvements in cardiopulmonary bypass technology, using low-prime circuits with retrograde autologous prime, have demonstrated a reduction in blood use while maintaining the surgical advantage of increased revascularization associated with on-pump surgery. A meta-analysis of published randomized clinical trials was used to compare the outcomes. These outcomes included the number of grafts, hospital length of stay, and transfusion rate. They were then incorporated into a decision-analysis model to compare OPCAB with the on-pump surgery, using both conventional high-prime (HP) and low-prime circuits with retrograde autologous prime (LP/RAP). The meta-analysis of randomized clinical trials revealed that OPCAB surgery had 0.33 less grafts (p < .05), a reduction of 0.97 days in hospital length of stay (LOS) (p < .05), and a 63.2% reduction in percentage of patients transfused (p < .05). Based on the decision-analysis model, a relatively low major event rate (defined as myocardial infarction, need for angioplasty or surgery) at 4 years of 2% can eliminate the savings associated with OPCAB when compared to a low-prime circuit with RAP. Using a 5% major event rate at 4 years, the predicted cost savings of LP/RAP over OPCAB is $510 per patient or $51,036,746 per 100,000 patients. The development and implementation of low-prime circuits with retrograde autologous prime is an import step in matching the outcomes associated with OPCAB surgery.
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Affiliation(s)
- JJ Sistino
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC
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Turi ZG. Intra-aortic Balloon Counterpulsation. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50009-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Amado LC, Kraitchman DL, Gerber BL, Castillo E, Boston RC, Grayzel J, Lima JAC. Reduction of "no-reflow" phenomenon by intra-aortic balloon counterpulsation in a randomized magnetic resonance imaging experimental study. J Am Coll Cardiol 2004; 43:1291-8. [PMID: 15063444 DOI: 10.1016/j.jacc.2003.11.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2003] [Revised: 11/03/2003] [Accepted: 11/18/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Intra-aortic balloon counterpulsation (IABC) can improve post-myocardial infarction (MI) outcomes, but the mechanisms of such effect remain unclear. We hypothesized that IABC augmentation reduces the extent of microvascular obstruction after acute infarction. BACKGROUND Microvascular obstruction or "no-reflow" (MO) has been shown to negatively influence left ventricular (LV) remodeling after myocardial infarction (MI). METHODS Seventeen dogs underwent 90 min of coronary artery occlusion followed by reperfusion. Animals were then randomized to either IABC (n = 9) or control (n = 8); IABC augmentation was performed for 24 h after MI. Microvascular obstruction and infarct size by first-pass and delayed contrast-enhanced magnetic resonance imaging (MRI) were measured at 1 and 24 h after reperfusion and compared with postmortem infarct size and MO by microspheres. RESULTS Microvascular obstruction by MRI, expressed as percent LV mass, decreased significantly in IABC (4.9 +/- 2.2% to 3.6 +/- 1.5%) and increased in controls (3.4 +/- 0.5% to 4.9 +/- 1.1% from 1 to 24 h, respectively; p < 0.001). Similar results were found for MO defined by microspheres. In the control group, MO increased significantly, during 24 h of study (from 8.8 +/- 1.7% to 43.2 +/- 11.1% of infarcted myocardium; p < 0.05), whereas not important change was observed in the IABC group (from 21.3 +/- 7.1% to 25.8 +/- 14.7%; p < 0.05 vs. control at 24 h). Infarct size, measured by MRI, increased in both groups (13.2 +/- 1.8 to 15.5 +/- 2.1 from 1 to 24 h, respectively; p < 0.05). CONCLUSIONS Intra-aortic balloon counterpulsation augmentation performed after reperfusion improves myocardial perfusion at the tissue level, and reduces the extent of no-reflow caused by microvascular obstruction.
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Affiliation(s)
- Luciano C Amado
- Department of Medicine, Division of Cardiology, Johns Hopkins University, School of Medicine, Baltimore, Maryland 21287-6568, USA
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Intra-aortic balloon counterpulsation pump therapy: a critical appraisal of the evidence for patients with acute myocardial infarction. Crit Care 1998; 2:3-8. [PMID: 11094470 PMCID: PMC3386655 DOI: 10.1186/cc117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/1998] [Indexed: 11/21/2022] Open
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