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Intra-aortic balloon pumping (IABP) is the most frequently utilized form of temporary mechanical support in cardiogenic shock. Withdrawal of IABP support occasionally precipitates hemodynamic compromise or collapse such that IABP reinsertion is considered or performed. The outcome of patients undergoing IABP reinsertion has not been formally studied.
Using the MedStar Washington Hospital Center Cardiac Care Unit (CCU) database, we identified a population of patients presenting with cardiogenic shock who required IABP reinsertion after failed wean. As a control we identified a matched population of patients who had received only a single IABP for cardiogenic shock. The primary outcome investigated was in-hospital mortality. Secondary outcomes included the utilization of other temporary or permanent methods of cardiac support, transplant, and discharge to hospice and a composite thereof.
20 subjects were eligible for inclusion in the study and 38 matched controls were identified, with both groups evenly matched at baseline. The incidence of in-hospital mortality was 70% in the reinsertion group and 31.2% in the controls (OR 2.2; p=0.005). The composite secondary endpoint of death, LVAD insertion during index hospitalization or discharge to hospice was also significantly higher in the reinsertion group than the controls (85% vs 42.1%; OR=2.0; p=0.002). We also performed multivariate analysis and found that use of multiple IABPs was independently predictive of in-hospital mortality (p<0.05).
Reinsertion of IABP after failure of initial wean is associated with extremely high in-hospital mortality and independently predicts mortality in patients with cardiogenic shock. This study supports the notion that if IABP weaning or removal is unsuccessful, alternative and more aggressive regimens of short or even long-term mechanical support be considered where appropriate such as surgical LVAD or extra-corporeal membrane oxygenation (ECMO).