Intra-aortic balloon pump. A cheap device to protect CHIP?

Variables that contribute to elevated risk during percutaneous coronary intervention (PCI) have been well defined and can be categorized into two major groups: 1) patient-specific, such as advanced age, poor left ventricular function, severe comorbidities, clinical presentation with acute coronary syndrome or cardiogenic shock; and 2) procedural-specific, such as complex anatomy, involvement of left main coronary artery or major bifurcations, heavy calcifications, chronic total occlusions, last patent vessel. Clinical features make these patients at high risk for standard coronary artery bypass grafting; nonetheless, they are also at high risk of intra-procedural complications with PCI and, whenever they are left untreated, they face a poor prognosis. High-risk PCI remains a challenge in modern interventional cardiology.
Catheter-based devices for mechanical circulatory support (MCS) aim both to overcome the inability of the heart to provide an adequate output and to sustain blood circulation and hemodynamics (Table I). Mechanistically, left ventricular support devices unload the failing left ventricle by reducing pre-load (volume unloading), after-load (pressure unloading) or both, whereas circulatory support increases mean arterial blood pressure. The ultimate goal is to improve or maintain myocardial, cerebral, mesenteric, renal, and peripheral tissue perfusion. MCS devices are routinely used during procedures on complex, higher-risk and indicated patients (CHIP), which are currently referred to as “protected PCI”. CHIP may frequently suffer intra-procedural sustained hypotension, which in turn jeopardizes coronary perfusion gradient. Loss of coronary perfusion leads to profound myocardial ischemia, which quickly depresses the already impaired left ventricle and may lead to cardiovascular collapse and cardiac arrest.
Intra-aortic balloon pump (IABP) is the simplest form of MCS (Table I). IABP aims to augment coronary and systemic blood flow during diastole while decreasing myocardial oxygen consumption and both left ventricular wall stress and workload. It only modestly enhances cardiac output. The demonstration of the protective role of elective IABP in protected PCI is still a controversial issue. Beyond historical positive data from observational studies [1], the largest randomized trial so far, the Balloon Pump-Assisted Coronary Intervention Study (BCIS-1), yielded negative results in the short term [2], but demonstrated a 34%...


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