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Liu Z, Liu X. Feasibility and Safety Study of Concomitant Left Bundle Branch Area Pacing and Atrioventricular Node Ablation with Same-Day Hospital Dismissal. J Clin Med 2023; 12:7002. [PMID: 38002617 PMCID: PMC10672577 DOI: 10.3390/jcm12227002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) has rapidly emerged as a promising modality of physiologic pacing and has demonstrated excellent lead stability. In this retrospective study, we evaluate whether this pacing modality can allow concomitant atrioventricular node (AVN) ablation and same-day dismissal. METHODS Twenty-four consecutive patients (female 63%, male 37%) with an average age of 78 ± 5 years were admitted for pacemaker (75%)/defibrillator (25%) implantations and concomitant AVN ablation. Device implantation with LBBAP was performed first, followed by concomitant AVN ablation through left axillary vein access to allow for quicker post-procedure ambulation. The patients were discharged on the same day after satisfactory post-ambulation device checks. RESULTS LBBAP was successful in 22 patients (92% in total, 20 patients had an LBBP and two patients had a likely LBBP), followed by AVN ablation from left axillary vein access (21/24, 88%). All patients had successful post-op chest x-rays, post-ambulation device checks, and were discharged on the same day. After a mean follow up of three months, no major complications occurred, such as LBBA lead dislodgement requiring a lead revision. The LBBA lead pacing parameters immediately after implantation vs. three-month follow up were a capture threshold of 0.8 ± 0.3 V@0.4 ms vs. 0.6 ± 0.3 V@0.4 ms, sensing 9.9 ± 3.9 mV vs. 10.4 ± 4.1 mV, and impedance of 710 ± 216 ohm vs. 544 ± 110 ohm. The QRS duration before and after AVN ablation was 117 ± 32 ms vs. 123 ± 14 ms. Mean LVEF before and three months after the implantation was 44 ± 14% vs. 46 ± 12%. CONCLUSION LBBA pacing not only offers physiologic pacing, but also allows for a concomitant AVN ablation approach from the left axillary vein and safe same-day hospital dismissal.
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Affiliation(s)
- Zhigang Liu
- Department of Cardiology, Ascension Borgess Hospital, Kalamazoo, MI 49048, USA
| | - Xiaoke Liu
- Department of Cardiovascular Medicine, Mayo Clinic Health System, La Crosse, WI 54601, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55901, USA
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Whinnett ZI, Shun‐Shin MJ, Tanner M, Foley P, Chandrasekaran B, Moore P, Adhya S, Qureshi N, Muthumala A, Lane R, Rinaldi A, Agarwal S, Leyva F, Behar J, Bassi S, Ng A, Scott P, Prasad R, Swinburn J, Tomson J, Sethi A, Shah J, Lim PB, Kyriacou A, Thomas D, Chuen J, Kamdar R, Kanagaratnam P, Mariveles M, Burden L, March K, Howard JP, Arnold A, Vijayaraman P, Stegemann B, Johnson N, Falaschetti E, Francis DP, Cleland JG, Keene D. Effects of haemodynamically atrio-ventricular optimized His bundle pacing on heart failure symptoms and exercise capacity: the His Optimized Pacing Evaluated for Heart Failure (HOPE-HF) randomized, double-blind, cross-over trial. Eur J Heart Fail 2023; 25:274-283. [PMID: 36404397 PMCID: PMC10946926 DOI: 10.1002/ejhf.2736] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS Excessive prolongation of PR interval impairs coupling of atrio-ventricular (AV) contraction, which reduces left ventricular pre-load and stroke volume, and worsens symptoms. His bundle pacing allows AV delay shortening while maintaining normal ventricular activation. HOPE-HF evaluated whether AV optimized His pacing is preferable to no-pacing, in a double-blind cross-over fashion, in patients with heart failure, left ventricular ejection fraction (LVEF) ≤40%, PR interval ≥200 ms and either QRS ≤140 ms or right bundle branch block. METHODS AND RESULTS Patients had atrial and His bundle leads implanted (and an implantable cardioverter-defibrillator lead if clinically indicated) and were randomized to 6 months of pacing and 6 months of no-pacing utilizing a cross-over design. The primary outcome was peak oxygen uptake during symptom-limited exercise. Quality of life, LVEF and patients' holistic symptomatic preference between arms were secondary outcomes. Overall, 167 patients were randomized: 90% men, 69 ± 10 years, QRS duration 124 ± 26 ms, PR interval 249 ± 59 ms, LVEF 33 ± 9%. Neither peak oxygen uptake (+0.25 ml/kg/min, 95% confidence interval [CI] -0.23 to +0.73, p = 0.3) nor LVEF (+0.5%, 95% CI -0.7 to 1.6, p = 0.4) changed with pacing but Minnesota Living with Heart Failure quality of life improved significantly (-3.7, 95% CI -7.1 to -0.3, p = 0.03). Seventy-six percent of patients preferred His bundle pacing-on and 24% pacing-off (p < 0.0001). CONCLUSION His bundle pacing did not increase peak oxygen uptake but, under double-blind conditions, significantly improved quality of life and was symptomatically preferred by the clear majority of patients. Ventricular pacing delivered via the His bundle did not adversely impact ventricular function during the 6 months.
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Affiliation(s)
- Zachary I. Whinnett
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | - Matthew J. Shun‐Shin
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | - Mark Tanner
- West Sussex Hospitals NHS TrustWest SussexUK
| | - Paul Foley
- Great Western Hospitals NHS Foundation TrustSwindonUK
| | | | - Philip Moore
- West Hertfordshire Hospitals NHS TrustHertfordshireUK
- Barts Health NHS TrustLondonUK
| | | | | | - Amal Muthumala
- Barts Health NHS TrustLondonUK
- North Middlesex University HospitalLondonUK
| | | | - Aldo Rinaldi
- Guy's and St. Thomas's NHS Foundation TrustLondonUK
| | | | | | | | - Sukh Bassi
- Sherwood Forest Hospitals NHS Foundation TrustUK
| | - Andre Ng
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
| | | | | | | | | | - Amarjit Sethi
- London North West University Healthcare NHS TrustLondonUK
| | - Jaymin Shah
- London North West University Healthcare NHS TrustLondonUK
| | - Phang Boon Lim
- National Heart and Lung InstituteImperial College LondonLondonUK
| | | | - Dewi Thomas
- Morriston Hospital Regional Cardiac CentreWalesUK
| | - Jenny Chuen
- Nottingham University Hospitals NHS TrustNottinghamUK
| | | | | | | | - Leah Burden
- Imperial College Healthcare NHS TrustLondonUK
| | | | - James P. Howard
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Ahran Arnold
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | | | | | | | | | | | | | - Daniel Keene
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
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Chugunov IA, Mareev YV, Fudim M, Mironova NA, Mareev VY, Davtyan RV. Cardiac contractility modulation in heart failure with reduced ejection fraction treatment. KARDIOLOGIIA 2022; 62:71-78. [DOI: 10.18087/cardio.2022.11.n2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/23/2022] [Accepted: 04/22/2022] [Indexed: 12/23/2022]
Abstract
Heart failure with reduced left ventricular ejection fraction (LV EF) (HFrEF) is a significant issue of health care due to increasing indexes of morbidity and mortality. The emergence of a number of drugs and implantable devices for the treatment of HFrEF has allowed improvement of patients’ well-being and prognosis. However, high mortality and recurrent decompensated heart failure remain a substantial issue and stimulate the search for new methods of CHF treatment. Cardiac contractility modulation (CCM) is a method of managing patients with HFrEF. Available data from randomized clinical trials (RCT) indicate the efficacy of CCM in improvement of patients’ well-being and quality of life. The question remains open: what effect does CCM have on LV reverse remodeling? Experimental data and results of observational studies suggest a possibility of reverse remodeling by CCM; however, this has not been confirmed in RCT. Also, it remains unclear how CCM influences the frequency of hospitalizations for decompensated heart failure and the death rate of patients with HFrEF. Results of both RCTs and observational studies have shown a moderate improvement of quality of life associated with CCM. Furthermore, RCTs have not found any increase in LV EF due to the therapy, nor has a meta-analysis of RCTs revealed any improvement of the prognosis associated with CCM. Further RCTs are needed to evaluate the effect of CCM on reverse remodeling, survival rate, and to determine the place of CCM in the treatment of patients with CHF.
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Affiliation(s)
- I. A. Chugunov
- National Medical Research Center of Therapy and Preventive Medicine
| | - Yu. V. Mareev
- National Medical Research Center of Therapy and Preventive Medicine; Robertson Centre for Biostatistics, Glasgow University
| | - M. Fudim
- Duke University, Duke Clinical Research Institute
| | | | - V. Yu. Mareev
- Medical Research and Educational Center, Lomonosov Moscow State University; School of Fundamental Medicine, Lomonosov Moscow State University
| | - R. V. Davtyan
- National Medical Research Center of Therapy and Preventive Medicine
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Multicenter Randomized Controlled Crossover Trial Comparing Hemodynamic Optimization Against Echocardiographic Optimization of AV and VV Delay of Cardiac Resynchronization Therapy: The BRAVO Trial. JACC Cardiovasc Imaging 2018; 12:1407-1416. [PMID: 29778861 PMCID: PMC6682561 DOI: 10.1016/j.jcmg.2018.02.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVES BRAVO (British Randomized Controlled Trial of AV and VV Optimization) is a multicenter, randomized, crossover, noninferiority trial comparing echocardiographic optimization of atrioventricular (AV) and interventricular delay with a noninvasive blood pressure method. BACKGROUND Cardiac resynchronization therapy including AV delay optimization confers clinical benefit, but the optimization requires time and expertise to perform. METHODS This study randomized patients to echocardiographic optimization or hemodynamic optimization using multiple-replicate beat-by-beat noninvasive blood pressure at baseline; after 6 months, participants were crossed over to the other optimization arm of the trial. The primary outcome was exercise capacity, quantified as peak exercise oxygen uptake. Secondary outcome measures were echocardiographic left ventricular (LV) remodeling, quality-of-life scores, and N-terminal pro-B-type natriuretic peptide. RESULTS A total of 401 patients were enrolled, the median age was 69 years, 78% of patients were men, and the New York Heart Association functional class was II in 84% and III in 16%. The primary endpoint, peak oxygen uptake, met the criterion for noninferiority (pnoninferiority = 0.0001), with no significant difference between the hemodynamically optimized arm and echocardiographically optimized arm of the trial (mean difference 0.1 ml/kg/min). Secondary endpoints for noninferiority were also met for symptoms (mean difference in Minnesota score 1; pnoninferiority = 0.002) and hormonal changes (mean change in N-terminal pro-B-type natriuretic peptide -10 pg/ml; pnoninferiority = 0.002). There was no significant difference in LV size (mean change in LV systolic dimension 1 mm; pnoninferiority < 0.001; LV diastolic dimension 0 mm; pnoninferiority <0.001). In 30% of patients the AV delay identified as optimal was more than 20 ms from the nominal setting of 120 ms. CONCLUSIONS Optimization of cardiac resynchronization therapy devices by using noninvasive blood pressure is noninferior to echocardiographic optimization. Therefore, noninvasive hemodynamic optimization is an acceptable alternative that has the potential to be automated and thus more easily implemented. (British Randomized Controlled Trial of AV and VV Optimization [BRAVO]; NCT01258829).
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Gamble JHP, Herring N, Ginks M, Rajappan K, Bashir Y, Betts TR. Endocardial left ventricular pacing for cardiac resynchronization: systematic review and meta-analysis. Europace 2017; 20:73-81. [DOI: 10.1093/europace/euw381] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/31/2016] [Indexed: 11/14/2022] Open
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Sohaib SMA, Wright I, Lim E, Moore P, Lim PB, Koawing M, Lefroy DC, Lusgarten D, Linton NWF, Davies DW, Peters NS, Kanagaratnam P, Francis DP, Whinnett ZI. Atrioventricular Optimized Direct His Bundle Pacing Improves Acute Hemodynamic Function in Patients With Heart Failure and PR Interval Prolongation Without Left Bundle Branch Block. JACC Clin Electrophysiol 2015; 1:582-591. [PMID: 29759412 DOI: 10.1016/j.jacep.2015.08.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/27/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate whether heart failure patients with narrow QRS duration (or right bundle branch block) but with long PR interval gain acute hemodynamic benefit from atrioventricular (AV) optimization. We tested this with biventricular pacing and (to deliver pure AV shortening) direct His bundle pacing. BACKGROUND Benefits of pacing for heart failure have previously been indicated by acute hemodynamic studies and verified in outcome studies. A new target for pacing in heart failure may be PR interval prolongation, which is associated with 58% higher mortality regardless of QRS duration. METHODS We enrolled 16 consecutive patients with systolic heart failure, PR interval prolongation (mean, 254 ± 62 ms) and narrow QRS duration (n = 13; mean QRS duration: 119 ± 17 ms) or right bundle branch block (n = 3; mean, QRS duration: 156 ± 18 ms). We successfully delivered temporary direct His bundle pacing in 14 patients and temporary biventricular pacing in 14 participants. We performed AV optimization using invasive systolic blood pressure obtaining parabolic responses (mean R2: 0.90 for His, and 0.85 for biventricular pacing). RESULTS The mean increment in systolic BP compared with intrinsic ventricular conduction was 4.1 mm Hg (95% confidence interval [CI]: +1.9 to +6.2 mm Hg for His and 4.3 mm Hg [95% CI: +2.0 to +6.5 mm Hg] for biventricular pacing. QRS duration lengthened with biventricular pacing (change = +22 ms [95% CI: +18 to +25 ms]) but not with His pacing (change = +0.5 ms [95% CI: -2.6 to +3.6 ms). CONCLUSIONS AV-optimized pacing improves acute hemodynamic function in patients with heart failure and long PR interval without left bundle branch block. That it can be achieved by single-site His pacing shows that its mechanism is AV shortening. The improvement is ∼60% of the effect size previously reported for biventricular pacing in left bundle branch block. Randomized, blinded trials are warranted to test for long-term beneficial effects.
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Affiliation(s)
- S M Afzal Sohaib
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Ian Wright
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Philip Moore
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - P Boon Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Michael Koawing
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - David C Lefroy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Daniel Lusgarten
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Nick W F Linton
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - D Wyn Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nicholas S Peters
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Darrel P Francis
- National Heart & Lung Institute, Imperial College London, London, United Kingdom.
| | - Zachary I Whinnett
- National Heart & Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
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Cole GD, Nowbar AN, Mielewczik M, Shun-Shin MJ, Francis DP. Frequency of discrepancies in retracted clinical trial reports versus unretracted reports: blinded case-control study. BMJ 2015; 351:h4708. [PMID: 26387520 PMCID: PMC4575810 DOI: 10.1136/bmj.h4708] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To compare the frequency of discrepancies in retracted reports of clinical trials with those in adjacent unretracted reports in the same journal. DESIGN Blinded case-control study. SETTING Journals in PubMed. POPULATION 50 manuscripts, classified on PubMed as retracted clinical trials, paired with 50 adjacent unretracted manuscripts from the same journals. Reports were randomly selected from PubMed in December 2012, with no restriction on publication date. Controls were the preceding unretracted clinical trial published in the same journal. All traces of retraction were removed. Three scientists, blinded to the retraction status of individual reports, reviewed all 100 trial reports for discrepancies. Discrepancies were pooled and cross checked before being counted into prespecified categories. Only then was the retraction status unblinded for analysis. MAIN OUTCOME MEASURE Total number of discrepancies (defined as mathematically or logically contradictory statements) in each clinical trial report. RESULTS Of 479 discrepancies found in the 100 trial reports, 348 were in the 50 retracted reports and 131 in the 50 unretracted reports. On average, individual retracted reports had a greater number of discrepancies than unretracted reports (median 4 (interquartile range 2-8.75) v 0 (0-5); P<0.001). Papers with a discrepancy were significantly more likely to be retracted than those without a discrepancy (odds ratio 5.7 (95% confidence interval 2.2 to 14.5); P<0.001). In particular, three types of discrepancy arose significantly more frequently in retracted than unretracted reports: factual discrepancies (P=0.002), arithmetical errors (P=0.01), and missed P values (P=0.02). Results from a retrospective analysis indicated that citations and journal impact factor were unlikely to affect the result. CONCLUSIONS Discrepancies in published trial reports should no longer be assumed to be unimportant. Scientists, blinded to retraction status and with no specialist skill in the field, identify significantly more discrepancies in retracted than unretracted reports of clinical trials. Discrepancies could be an early and accessible signal of unreliability in clinical trial reports.
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Affiliation(s)
- Graham D Cole
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Alexandra N Nowbar
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Michael Mielewczik
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
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Cleland JG, Mareev Y, Linde C. Reflections on EchoCRT: sound guidance on QRS duration and morphology for CRT?: Figure 1. Eur Heart J 2015; 36:1948-51. [DOI: 10.1093/eurheartj/ehv264] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Jackson T, Claridge S, Behar J, Sammut E, Webb J, Carr-White G, Razavi R, Rinaldi CA. Narrow QRS systolic heart failure: is there a target for cardiac resynchronization? Expert Rev Cardiovasc Ther 2015; 13:783-97. [PMID: 26048215 DOI: 10.1586/14779072.2015.1049945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac resynchronization therapy has revolutionized the management of systolic heart failure in patients with prolonged QRS during the past 20 years. Initially, the use of this treatment in patients with shorter QRS durations showed promising results, which have since been opposed by larger randomized controlled trials. Despite this, some questions remain, such as, whether correction of mechanical dyssynchrony is the therapeutic target by which biventricular pacing may confer benefit in this group, or are there other mechanisms that need consideration? In addition, novel techniques of cardiac resynchronization therapy delivery such as endocardial and multisite pacing may reduce potential detrimental effects of biventricular pacing, thereby improving the benefit/harm balance of this therapy in some patients.
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Affiliation(s)
- Tom Jackson
- Department of Cardiovascular Imaging, 4th Floor Lambeth Wing, St Thomas' Hospital, London, SE1 7EH, UK
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Ahmad Y, Sen S, Shun-Shin MJ, Ouyang J, Finegold JA, Al-Lamee RK, Davies JER, Cole GD, Francis DP. Intra-aortic Balloon Pump Therapy for Acute Myocardial Infarction: A Meta-analysis. JAMA Intern Med 2015; 175:931-939. [PMID: 25822657 DOI: 10.1001/jamainternmed.2015.0569] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Intra-aortic balloon pump (IABP) therapy is a widely used intervention for acute myocardial infarction with cardiogenic shock. Guidelines, which previously strongly recommended it, have recently undergone substantial change. OBJECTIVE To assess IABP efficacy in acute myocardial infarction. DATA SOURCES Human studies found in Pubmed, Embase, and Cochrane libraries through December 2014 and in reference lists of selected articles. Search strings were "myocardial infarction" or "acute coronary syndrome" and "intra-aortic balloon pump" or "counterpulsation." STUDY SELECTION Randomized clinical trials (RCTs) and observational studies comparing use of IABP with no IABP in patients with acute myocardial infarction. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted the data, and risk of bias in RCTs was assessed using the Cochrane risk of bias tool. We conducted separate meta-analyses of the RCTs and observational studies. Data were quantitatively synthesized using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Thirty-day mortality. RESULTS There were 12 eligible RCTs randomizing 2123 patients. In the RCTs, IABP use had no statistically significant effect on mortality (odds ratio [OR], 0.96 [95% CI, 0.74-1.24]), with no significant heterogeneity among trials (I2 = 0%; P = .52). This result was consistent when studies were stratified by the presence (OR, 0.94 [95% CI, 0.69-1.28]; P = .69, I2 = 0%) or absence (OR, 0.98 [95% CI, 0.57-1.69]; P = .95, I2 = 17%) of cardiogenic shock. There were 15 eligible observational studies totaling 15 530 patients. Their results were mutually conflicting (heterogeneity I2 = 97%; P < .001), causing wide uncertainty in the summary estimate for the association with mortality (OR, 0.96 [95% CI, 0.54-1.70]). A simple index of baseline risk marker imbalance in the observational studies appeared to explain much of the heterogeneity in the observational data (R2meta = 46.2%; P < .001). CONCLUSIONS AND RELEVANCE Use of IABP was not found to improve mortality among patients with acute myocardial infarction in the RCTs, regardless of whether patients had cardiogenic shock. The observational studies showed a variety of mutually contradictory associations between IABP therapy and mortality, much of which was explained by the differences between studies in the balance of risk factors between IABP and non-IABP groups.
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Affiliation(s)
- Yousif Ahmad
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Sayan Sen
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jing Ouyang
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rasha K Al-Lamee
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Justin E R Davies
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Graham D Cole
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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