Effects of intra-aortic balloon counterpulsation pump on mortality of acute myocardial infarction

Effects of mechanical circulatory support devices in patients with acute myocardial infarction undergoing stent implantation: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

The survival benefit of using mechanical circulatory support (MCS) in patients with acute myocardial infarction (AMI) is still controversial. It is necessary to explore the impact on clinical outcomes of MCS in patients with AMI undergoing stenting.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Cochrane Library, Medline, PubMed, Web of Science, ClinicalTrials.gov and Clinicaltrialsregister.eu databases were searched from database inception to February 2021.

ELIGIBILITY CRITERIA

Randomised clinical trials (RCTs) on MCS use in patients with AMI undergoing stent implantation were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and summarised independently by two reviewers. Risk ratios (RRs) and 95% CIs were calculated for clinical outcomes according to random-effects model.

RESULTS

Twelve studies of 1497 patients with AMI were included, nine studies including 1382 patients compared MCS with non-MCS, and three studies including 115 patients compared percutaneous ventricular assist devices (pVADs) versus intra-aortic balloon pump (IABP). Compared with non-MCS, MCS was not associated with short-term (within 30 days) (RR=0.90; 95% CI 0.57 to 1.41; I²=46.8%) and long-term (at least 6 months) (RR=0.82; 95% CI 0.57 to 1.17; I²=37.6%) mortality reductions. In the subset of patients without cardiogenic shock (CS) compared with non-MCS, the patients with IABP treatment significantly had decreased long-term mortality (RR=0.49; 95% CI 0.27 to 0.90; I²=0), but without the short-term mortality reductions (RR=0.51; 95% CI 0.22 to 1.19; I²=17.9%). While in the patients with CS, the patients with MCS did not benefit from the short-term (RR=1.09; 95% CI 0.67 to 1.79; I²=46.6%) or long-term (RR=1.00; 95% CI 0.75 to 1.33; I²=22.1%) survival. Moreover, the application of pVADs increased risk of bleeding (RR=1.86; 95% CI 1.15 to 3.00; I²=15.3%) compared with IABP treatment (RR=1.86; 95% CI 1.15 to 3.00; I²=15.3%).

CONCLUSIONS

In all patients with AMI undergoing stent implantation, the MCS use does not reduce all-cause mortality. Patients without CS can benefit from MCS regarding long-term survival, while patients with CS seem not.

Comparison of the prognosis for different onset stage of cardiogenic shock secondary to ST-segment elevation myocardial infarction

Objectives

The study was conducted to evaluate the outcomes of different onset stage of cardiogenic shock (CS) in the patients with ST-segment elevation myocardial infarction (STEMI).

Methods

Total 675 STEMI patients who had undergone primary percutaneous coronary intervention (pPCI) from November 2010 to December 2017 in Nanjing Drum Tower Hospital were enrolled. According to the onset time of CS, the cohort was divided into three groups: Non-CS group, CS on admission group and Developed CS group. The short-term (30 days), middle-term (12 months) and long-term (80 months) outcomes were analyzed. COX proportional hazard models were established for identification of the predictors.

Results

The all cause death, cardiac death and major adverse cardiac events (MACE) at 30 days were similar among the three groups. The incidence of MACE in the CS on admission group was significantly higher than the other two groups at 12 months. As to the long-term outcomes, the CS on admission group had lower survival rate than the other two groups. The Develop CS group had lower survival rate than Non-CS group numerically with a trend towards statistical significance. The incidence of cardiac death in the Non-CS group was the lowest. The incidence of MACE in the CS on admission group was much higher compared with the other two groups. After multivariate analysis, the independent predictors of all cause death included age, male sex, prior stroke and LVEF. The independent predictors of cardiac death included age, male sex, prior stroke, LVEF, CS on admission and developed CS. The independent predictors of MACE included age, prior stroke, LVEF, multivessel lesions, post-PCI TIMI grade 1 and CS on admission.

Conclusions

The long-term outcomes of CS on admission group were the worst of all. The outcomes of Developed CS group laid between the other two groups. The consequences highlighted the importance of prevention for CS developing in the STEMI patients during hospitalization.

The effectiveness of intra-aortic balloon pump for myocardial infarction in patients with or without cardiogenic shock: a meta-analysis and systematic review

Background

Conflicting reports on the efficacy of intra-aortic balloon pump (IABP) during percutaneous coronary intervention (PCI) incited us to evaluate the utility of IABP in patients with acute myocardial infarction (AMI).

Methods

Randomized clinical trials comparing patients, who received IABP vs. control (no IABP) during PCI, were hand-searched from MEDLINE, Cochrane, and EMBASE databases using the terms “intra-aortic balloon pump, percutaneous coronary intervention, myocardial infarction, acute coronary syndrome”. Mortality rate (30-day and 6-month mortality) was the primary outcome, while the secondary outcomes included 30-day bleeding rate, reinfarction rate, revascularization rate and stroke rate.

Results

Pooled results of the seven trials identified indicated that the 30-day and 6-month mortality rate were not significantly different between the IABP and control groups. However, in patients with MI, but without cardiogenic shock (CS), IABP was associated with lower odds of 30-day mortality (OR = 0.35, p = 0.015) and 6-month mortality (OR = 0.41, p = 0.020). The pooled results of 30-day bleeding rate was not significantly higher in patients with IABP than the control group, but for the patients with high risk PCI without CS, it was higher in patients with IABP than the control group (OR = 1.58, p = 0.009). The re-infarction, revascularization, and the stroke rate at 30 days of follow-up were not significantly different between the two groups.

Conclusions

The present results do not favor the clinical utility of IABP in patients suffering high-risk PCI without CS and AMI complicated with CS. However, in patients with AMI, but without CS, IABP may reduce the 30-day and 6-month mortality rate.

[Predictors of morbidity and mortality in patients undergoing intra-aortic counterpulsation balloon in cardiac surgery]

Le ballon de contre pulsion intra-aortique (BCPIA) est fréquemment utilisé en chirurgie cardiaque, comme moyen d'assistance circulatoire en cas de bas débit cardiaque. Il est d'intérêt clinique de déterminer les facteurs pronostiques chez les patients porteurs d'un BCPIA en chirurgie cardiaque, et qui restent un sujet rarement élucidé dans la littérature. L'objectif de notre travail est de déterminer les facteurs prédictifs de morbi-mortalité chez les patients sous ballon de contre pulsion intraortique en périopératoire d'une chirurgie cardiaque. Il s'agit d'une étude rétrospective portant sur l'ensemble des patients opérés en chirurgie cardiaque sous circulation extracorporelle, et ayant bénéficiés de la mise en place d'un ballon de contre pulsion intra-aortique en périopératoire, au service de chirurgie cardiovasculaire de l'Hôpital Militaire Mohamed V de Rabat, entre le mois de janvier 2005 et le mois d'aout 20014. Soixante dix patients ont été inclus dans notre étude. En analyse univariée l'âge, la dyspnée de stade III et IV, l'insuffisance cardiaque, la présence d'un infarctus du myocarde, d'une coronaropathie mono et bitronculaire, les anomalies du doppler de trons supra-aortique et du membre inférieur, le caractère urgent de la chirurgie, la durée de la circulation extracorporelle, l'instabilité hémodynamique postopératoire, le saignement et l'insuffisance rénale postopératoire étaient statistiquement associés à une mortalité postopératoire élevée. La dyskinésie préopératoire et la sortie de circulation extracorporelle sous drogues étaient associées à une morbidité globale élevée. En analyse multi variée, seule l'âge, constituait un facteur de risque indépendant de mortalité dans notre série avec un Odds Ratio (OR): 1,89 ; un Intervalle de Confiance (IC) 95% de (1,52-4,97) et un p =0,045. Au terme de notre étude, le taux de mortalité était de 48,57% et de morbidité globale était de 87,1%. Il nous parait donc nécessaire pour diminuer l'incidence de cette morbimortalité dans notre population, d'agir sur les facteurs que nous jugeons modifiables tels l'amélioration de la fonction cardiaque préopératoire, l'optimisation de la fonction rénale, la réduction de la durée de CEC et le contrôle du saignement.