Withdrawing intra-aortic balloon pump support paradoxically improves microvascular flow

Abstract

IntroductionThe Intra-Aortic Balloon Pump (IABP) is frequently used to mechanically support the heart. There is evidence that IABP improves microvascular flow during cardiogenic shock but its influence on the human microcirculation in patients deemed ready for discontinuing IABP support has not yet been studied. Therefore we used sidestream dark field imaging (SDF) to test our hypothesis that human microcirculation remains unaltered with or without IABP support in patients clinically ready for discontinuation of mechanical support.MethodsWe studied 15 ICU patients on IABP therapy. Measurements were performed after the clinical decision was made to remove the balloon catheter. We recorded global hemodynamic parameters and performed venous oximetry during maximal IABP support (1:1) and 10 minutes after temporarily stopping the IABP therapy. At both time points, we also recorded video clips of the sublingual microcirculation. From these we determined indices of microvascular perfusion including perfused vessel density (PVD) and microvascular flow index (MFI).ResultsCeasing IABP support lowered mean arterial pressure (74 ± 8 to 71 ± 10 mmHg; P = 0.048) and increased diastolic pressure (43 ± 10 to 53 ± 9 mmHg; P = 0.0002). However, at the level of the microcirculation we found an increase of PVD of small vessels <20 μm (5.47 ± 1.76 to 6.63 ± 1.90; P = 0.0039). PVD for vessels >20 μm and MFI for both small and large vessels were unaltered. During the procedure global oxygenation parameters (ScvO2/SvO2) remained unchanged.ConclusionsIn patients deemed ready for discontinuing IABP support according to current practice, SDF imaging showed an increase of microcirculatory flow of small vessels after ceasing IABP therapy. This observation may indicate that IABP impairs microvascular perfusion in recovered patients, although this warrants confirmation.

Coronary versus carotid blood flow and coronary perfusion pressure in a pig model of prolonged cardiac arrest treated by different modes of venoarterial ECMO and intraaortic balloon counterpulsation

“…Accordingly, the direction of outflow arterial flow and distance from coronaries is also of importance [28]. Our results add to the controversy about the effect of IABP-generated pulsatility both on macro- and microcirculation; in small non-randomized clinical studies, Jung [36,37] and den Uil [38] have reported on a favorable effect of IABP on microcirculation in cardiogenic shock, but Mustermann [39] showed paradoxically improved microvascular flow after withdrawing the IABP. Microcirculation changes definitely play a key role in critical states [40-42] and the role of pulsatility and different support combinations (that is, central vs. peripheral, subclavian vs. femoral) on microcirculatory changes remains to be further studied.…”

Haemodialysis Impairs the Human Microcirculation Independent from Macrohemodynamic Parameters

“…Because of the emergence of Sidestream Dark Field (SDF) imaging and similar techniques, it has now become possible to visualise the central human microcirculation in real time [7]. This has generated a large body of evidence in septic patients and patients with cardiogenic circulatory failure that global and regional hemodynamic parameters do not necessarily reflect microvascular perfusion [4,8,9]. However, in the setting of HD, microcirculation has not been extensively studied.…”

Interleukin-6, -7, -8 and -10 predict outcome in acute myocardial infarction complicated by cardiogenic shock

“…In patients deemed ready for discontinuing IABP support according to current practice an increase of microcirculatory flow of small vessels after ceasing IABP therapy could be observed. The authors speculated whether this observation may indicate that IABP impairs microvascular perfusion in recovered patients [35].…”