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Role of intra-aortic balloon pumping on cerebral perfusion after cardiac arrest
Resuscitation 84 (2013) e5
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Role of intra-aortic balloon pumping on cerebral perfusion after cardiac arrest Sir, We read with great interest the paper by Maze et al.1 Their primary outcome of survival to hospital discharge in good neurological condition was reached in 60% of their post-CA patients. When comparing the two groups (good to poor neurological outcome or death), they found that patients with good neurological recovery were younger and had higher baseline creatinine clearance. They did not observe any further difference between good and poor outcome (or death) in terms of CPR (no-flow or low-flow time, time to cooling), nor in terms of cardiac catheterization (preand post-PCI TIMI flow), neither in terms of therapeutic hypothermia and adverse events (bleeding outcomes, need for dialysis, ischemic stroke or re-infarction). However, patients with good outcome were more likely to have an intra-aortic balloon pump (IABP) inserted (9 pts or 30%) versus 1 pt (5%) with poor outcome (or death) respectively. In their discussion, the authors did not give any further explanation to this striking observation. Did the increased incidence of IABP-use in the group with good outcome result in a significant increase in mean arterial pressure compared to the group with poor outcome or death? What was the indication for the use of IABP, as referring to the reported incidence of cardiogenic shock, there was a incidence of 43% cardiogenic shock in the group with good outcome versus 50% in the group with death or poor outcome. Since patients with a good outcome were also younger, a selection bias might be present (younger patients with shock were treated more aggressively, e.g. with IABP). The role of IABP in those patients with a good neurological outcome might be more relevant. The use of IABP, by its diastolic augmentation, results in a higher mean arterial pressure2 and it is well-known that the mean arterial pressure is the driving pressure behind the cerebral perfusion pressure. It was reported that IABP significantly increased antegrade mean flow in the middle cerebral artery (measured by transcranial Doppler ultrasound).3 Therefore, these higher mean arterial pressures (and hence higher cerebral perfusion pressures) during the first hours after cardiac arrest might be beneficial for the overall cerebral perfusion and for final neurological outcome. On the other hand, a recent paper by Thiele et al.4 reported that the use of IABP, as compared with conventional therapy, did not reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction and in whom an early revascularization strategy was planned. In their paper, although
0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2012.09.039
38% of pts suffered from cardiac arrest and underwent therapeutic hypothermia, no data were provided concerning neurological outcome. Conclusion: perhaps the use of IABP might play a beneficial role in the neurological outcome in young cardiogenic shock patients (by increasing cerebral perfusion in the early hours after cardiac arrest). It seems appropriate that future studies should investigate the potential role of IABP in the setting of cardiac arrest with cardiogenic shock with respect to its influence on cerebral perfusion, and hence final neurological outcome. Conflict of interest statement No conflict of interest to declare. References 1. Maze R, Le May M, Hibbert B, et al. The impact of therapeutic hypothermia as adjunctive therapy in a regional primary PCI program. Resuscitation 2012, http://dx.doi.org/10.1016/j.resuscitation.2012.08.2002. 2. Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol 2006;97:1391–8. 3. Schachtrupp A, Wrigge H, Busch T, et al. Influence on intra-aortic balloon pumping on cerebral blood flow patterns in patients after cardiac surgery. Eur J Anaesthesiol 2005;22:163–70. 4. Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012;367:1287–96.
Cathy De Deyne a,b,∗ Ingrid Meex a,b a Department of Critical Care Medicine, Ziekenhuis Oost-Limburg Genk, Belgium b Faculty of Medicine and Life Sciences, Hasselt University, Belgium a
Jo Dens a,b Department of Cardiology, Ziekenhuis Oost-Limburg Genk, Belgium b Faculty of Medicine and Life Sciences, Hasselt University, Belgium ∗ Corresponding
author at: Department of Critical Care Medicine, Ziekenhuis Oost-Limburg Genk, Belgium. Tel.: +32 89325296. E-mail address: [email protected] (C. De Deyne) 29 September 2012
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Role of intra-aortic balloon pumping on cerebral perfusion after cardiac arrest Sir, We read with great interest the paper by Maze et al.1 Their primary outcome of survival to hospital discharge in good neurological condition was reached in 60% of their post-CA patients. When comparing the two groups (good to poor neurological outcome or death), they found that patients with good neurological recovery were younger and had higher baseline creatinine clearance. They did not observe any further difference between good and poor outcome (or death) in terms of CPR (no-flow or low-flow time, time to cooling), nor in terms of cardiac catheterization (preand post-PCI TIMI flow), neither in terms of therapeutic hypothermia and adverse events (bleeding outcomes, need for dialysis, ischemic stroke or re-infarction). However, patients with good outcome were more likely to have an intra-aortic balloon pump (IABP) inserted (9 pts or 30%) versus 1 pt (5%) with poor outcome (or death) respectively. In their discussion, the authors did not give any further explanation to this striking observation. Did the increased incidence of IABP-use in the group with good outcome result in a significant increase in mean arterial pressure compared to the group with poor outcome or death? What was the indication for the use of IABP, as referring to the reported incidence of cardiogenic shock, there was a incidence of 43% cardiogenic shock in the group with good outcome versus 50% in the group with death or poor outcome. Since patients with a good outcome were also younger, a selection bias might be present (younger patients with shock were treated more aggressively, e.g. with IABP). The role of IABP in those patients with a good neurological outcome might be more relevant. The use of IABP, by its diastolic augmentation, results in a higher mean arterial pressure2 and it is well-known that the mean arterial pressure is the driving pressure behind the cerebral perfusion pressure. It was reported that IABP significantly increased antegrade mean flow in the middle cerebral artery (measured by transcranial Doppler ultrasound).3 Therefore, these higher mean arterial pressures (and hence higher cerebral perfusion pressures) during the first hours after cardiac arrest might be beneficial for the overall cerebral perfusion and for final neurological outcome. On the other hand, a recent paper by Thiele et al.4 reported that the use of IABP, as compared with conventional therapy, did not reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction and in whom an early revascularization strategy was planned. In their paper, although
0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2012.09.039
38% of pts suffered from cardiac arrest and underwent therapeutic hypothermia, no data were provided concerning neurological outcome. Conclusion: perhaps the use of IABP might play a beneficial role in the neurological outcome in young cardiogenic shock patients (by increasing cerebral perfusion in the early hours after cardiac arrest). It seems appropriate that future studies should investigate the potential role of IABP in the setting of cardiac arrest with cardiogenic shock with respect to its influence on cerebral perfusion, and hence final neurological outcome. Conflict of interest statement No conflict of interest to declare. References 1. Maze R, Le May M, Hibbert B, et al. The impact of therapeutic hypothermia as adjunctive therapy in a regional primary PCI program. Resuscitation 2012, http://dx.doi.org/10.1016/j.resuscitation.2012.08.2002. 2. Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol 2006;97:1391–8. 3. Schachtrupp A, Wrigge H, Busch T, et al. Influence on intra-aortic balloon pumping on cerebral blood flow patterns in patients after cardiac surgery. Eur J Anaesthesiol 2005;22:163–70. 4. Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012;367:1287–96.
Cathy De Deyne a,b,∗ Ingrid Meex a,b a Department of Critical Care Medicine, Ziekenhuis Oost-Limburg Genk, Belgium b Faculty of Medicine and Life Sciences, Hasselt University, Belgium a
Jo Dens a,b Department of Cardiology, Ziekenhuis Oost-Limburg Genk, Belgium b Faculty of Medicine and Life Sciences, Hasselt University, Belgium ∗ Corresponding
author at: Department of Critical Care Medicine, Ziekenhuis Oost-Limburg Genk, Belgium. Tel.: +32 89325296. E-mail address: [email protected] (C. De Deyne) 29 September 2012