Routine intra-aortic balloon pump support in high-risk cardiac surgery patients: Is it time to throw away the pump?

摘要

Forty years ago, the intra-aortic balloon pump (IABP) was first reported to be used for the treatment of patients in shock after cardiopulmonary bypass (1). Preoperative use of the device in high-risk patients with severe left main disease or depressed left ventricular function undergoing myo-cardial revascularization was described shortly thereafter (2). While in the ensuing decades, prophylactic IABP support for high-risk patients undergoing cardiac surgery has become established in the practice of surgical centers, and the evidence to support routine use of this strategy is not particularly robust with only four randomized trials having been completed, all small, and with fewer than 300 patients in total having been studied (3, 4). Although meta-analyses of these trials are suggestive of benefit of preoperative IABP deployment (3,4), a number of methodological issues identified by the more recent Cochrane systematic review render the data less than conclusive (4). Nonrandomized studies included in the earlier meta-analysis were in fact less suggestive of a benefit of the routine preoperative IABP strategy, their results having been possibly affected by the selection of higher risk patients to receive preoperative IABP therapy (3). As a result, surgical practice guidelines are silent on the prophylactic use of the IABP (5), with only the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines even mentioning the use of the IABP and then only as a recommendation for use in case of hemodynamic impairment (6).