1. IABP用于高危PCI有价值吗? Is IABP Valuable for High-Risk PCI? 刘斌
吉林大学第二医院心血管医院

2. Physiological basis of IABP
Intra-aortic balloon pump: indications, efficacy, guidelines and future directions. Curr.Opin Cardiol Jul;29(4):

3. IABP for High-Risk PCI High-risk PCI:
impaired left ventricular function
significant ischemia risk in a large fraction of the myocardium
impending hemodynamic instability
acute myocardial infarction(AMI)
Routine indications of IABP for high-risk PCI:
cardiogenic shock
ST-segment elevation myocardial infarction(STEMI)
other high-risk situations
Intra-aortic balloon pump: indications, efficacy, guidelines and future directions. Curr.Opin Cardiol Jul;29(4):
Intra-aortic balloon pump use in high-risk percutaneous coronary intervention. Curr.Opin Cardiol. 2013;28:

4. 2004 ACC/AHA STEMI Guideline
Class I
IABP should be used in STEMI patients with Hypotention.(B)
IABP is recommended for STEMI patients with low-output state.(B)
IABP is recommended for STEMI patients when cardiogenic shock is not quickly reversed with pharmacological therapy.(B)
IABP should be used in addition to medical therapy for STEMI patients with recurrent ischemic-type chest discomfort and signs of hemodynamic instability,poor LV function, or a large area of myocardium at risk.(C)
Class IIa
It is reasonable to manage STEMI patients with refractory polymorphic VT with IABP to reduce myocardial ishemia.(B)

5. Recent data for IABP
Intra-aortic balloon pump: indications, efficacy, guidelines and future directions. Curr.Opin Cardiol Jul;29(4):

6. IABP in AMI without shock
JAMA, September 28, 2011—Vol 306, No. 12

7. IABP in MI without shock
Primary end point：infarct size：p=0.06
Second end point：all-cause death at 6 months:p=0.12
no significant differences
JAMA, September 28, 2011—Vol 306, No. 12

8. IABP in MI without shock
European Heart Journal (2009) 30, 459–468
Am Heart J Jul;164(1):58-65

9. IABP in MI without shock

10. IABP in MI without shock
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:Circulation 2013; 127:e362–e425.
ESC guidelines for the management of STEMI elevation.Eur Heart J 2012; 33:2569–

11. IABP in cardiogenic shock
IABP-SHOCK II :
the largest randomized control trial ever performed in cardiogenic shock - randomised 600 patients enrolled in 37 centres in Germany from June 2009 to March 2012
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:

12. IABP-SHOCK II STUDY
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:

13. IABP-SHOCK II STUDY Primary Study Endpoint: 30-DAY Morality
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:

14. IABP-SHOCK II STUDY
Lancet.2013 Nov 16;382(9905):

15. IABP-SHOCK II STUDY Conclusions：
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:
Lancet.2013 Nov 16;382(9905):

16. IABP in cardiogenic shock
Am Heart J May;165(5):

17. IABP in cardiogenic shock
Am Heart J May;165(5):

18. IABP in cardiogenic shock
Am Heart J May;165(5):

19. IABP in cardiogenic shock
Am Heart J May;165(5):

20. European Heart Journal (2009) 30, 459–468

21. IABP in cardiogenic shock
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:Circulation 2013; 127:e362–e425.
2014 ESC/EACTS guidelines on myocardial revascularization:European Heart J (2014)35;

22. Ballon pump assited coronary intervention study(BCIS-1)
IABP in high-risk PCI
Ballon pump assited coronary intervention study(BCIS-1)
JAMA 2010,304(8):

23. Ballon pump assited coronary intervention study(BCIS-1)
JAMA 2010,304(8):

24. Ballon pump assited coronary intervention study(BCIS-1)
Major outcomes: MACCE
MACCE：
15.2% vs 16.0% p=0.85
Death:2.0% vs 0.7%, p=0.34
MI:12.6% vs 13.3%, p=0.85
Revasculatization:
0.7% vs 2.7%, p=0.21
Complications:
1.3% vs 10.7% p<0.001
JAMA 2010,304(8):

25. Ballon pump assited coronary intervention study(BCIS-1)
Secondary outcomes:6 month motality
P=0.32
JAMA 2010,304(8):

27. IABP in high-risk PCI
. Lack of intra-aortic balloon pump effectiveness in high-risk percutaneous coronary interventions without cardiogenic shock: a comprehensive meta-analysis of randomised trials andobservational studies. Int J Cardiol 2013; 167:1783–1793.

28. . Lack of intra-aortic balloon pump effectiveness in high-risk percutaneous coronary interventions without cardiogenic shock: a comprehensive meta-analysis of randomised trials andobservational studies. Int J Cardiol 2013; 167:1783–1793.

29. IABP in high-risk PCI
. Lack of intra-aortic balloon pump effectiveness in high-risk percutaneous coronary interventions without cardiogenic shock: a comprehensive meta-analysis of randomised trials andobservational studies. Int J Cardiol 2013; 167:1783–1793.

30. IABP in high-risk PCI
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:Circulation 2013; 127:e362–e425.
ESC guidelines for the management of STEMI elevation.Eur Heart J 2012; 33:2569–

31. limititions
Lower mortality rates were observed than reported in previous registries.
Cross-over rates between groups are high in all trials.
Data remains to be conflicting.
The longer-term follow-up from the BCIS-1 trial showed a significant reduction in all-cause mortality among IABP group,the mechanism of this benefit is still unclear.

32. SUMMARY
The recent 3 major trials (CRISP-AMI, IABP-SHOCK II, BCIS-1) and all meta-analyses evaluating the routine use of IABP in different high-risk situations failed to show evidence of efficacy.
All these trials did establish the safety of IABP in high-risk patients without any increased vascular or bleeding complications even in emergency situations such as AMI.
The usage of IABP in high-risk PCI sould be more careful, selective and individualized.
Larger RCTs with long-term follow-up and a better understanding of physiological aspects of IABP are still to be demanded.

33. Thanks