Current and future applications of the intra-aortic balloon pump

PURPOSE OF REVIEW: The intra-aortic balloon pump (IABP) has been used for more than 40 years. Although recommended in a wide variety of clinical settings, most of these indications are not evidence-based. This review focuses on studies challenging these traditional indications and evaluates potentially new applications of intra-aortic counterpulsation. RECENT FINDINGS: Recent studies have failed to confirm an improvement in clinical outcomes conferred by the IABP in patients developing cardiogenic shock after acute myocardial infarction. This issue is in need of further investigations. While conflicting results of several retrospective studies and meta-analyses have been published regarding the performance of the IABP in high-risk percutaneous coronary interventions, it has recently been found to improve the long-term clinical outcomes of patients in whom it was implanted before the procedure. Small, single-center studies have reported the use of the IABP as a bridge to transplantation or candidacy for left-ventricular assist device implantation. The recently reported feasibility and safety of its insertion via the subclavian or axillary arteries will facilitate these applications. SUMMARY: The revisiting of available data and the performance of new, thoughtfully designed trials should clarify the proper indications for the IABP. © 2014 Wolters Kluwer Health

Experimental and Clinical Evaluation of a Counterpulsation Device

The counterpulsation technique has been widely used for the as sistance of the acutely failing left ventricle utilizing the intraaortic balloon pump. However, a variety of other counterpulsation devices are available. To evaluate a counterpulsation device several variables need to be considered: (1) experimental and clinical determination of the salutary effects of the device on the left ventricular ejection fraction, cardiac output, aortic pressures, left ven tricular end-diastolic pressure, tension-time index, diastolic pressure-time in dex and endocardial viability ratio; (2) experimental and clinical estimation of the device biocompatibility, and (3) the clinical improvement of the assisted patients. © 1990, Sage Publications. All rights reserved

Anemia in heart failure: Should we supplement iron in patients with chronic heart failure?

Anemia has been identified as an independent prognostic factor of both morbidity and mortality for patients with congestive heart failure (CHF). The association between anemia and adverse outcomes has raised the hypothesis that anemia correction might lead to an improvement in the prognosis of patients with CHF. Nevertheless, data from large randomized trials about the effect of anemia correction on patient outcome are still lacking. Numerous clinical studies, randomized and nonrandomized, have evaluated the efficacy of erythropoietin or iron supplementation for treating anemia in patients with CHF, and their effect on patient symptoms and functional status. The superiority of any of these approaches has not been established yet. This review will discuss different treatment options for anemic patients with CHF, with emphasis on the correction of iron deficiency. Copyright by Medycyna Praktyczna, 2010

Anemia in heart failure: Pathophysiologic insights and treatment options

Anemia has been recognized as a very common and serious comorbidity in heart failure, with a prevalence ranging from 10 to 79%, depending on diagnostic definition, disease severity and patient characteristics. A clear association of anemia with worse prognosis has been confirmed in multiple heart failure trials. This finding has recently triggered intense scrutiny in order to identify the underlying pathophysiology and the best treatment options. Etiology is multifactorial, with iron deficiency and cytokine activation (anemia of chronic disease) playing the most important roles. Treatment is aimed at not only restoring hemoglobin values back to normal, but also at improving the patient's symptoms, functional capacity and hopefully the outcome. Iron supplementation and erythropoietin-stimulating agents have been used for this purpose, either alone or in combination. In this review, the recent advances in elucidating the mechanisms leading to anemia in the setting of heart failure are presented and the evidence supporting the use of different treatment approaches are discussed. © 2009 Future Medicine

Reverse cardiac remodeling enabled by mechanical unloading of the left ventricle

Cardiac remodeling is a characteristic and basic component of heart failure progression and is associated with a poor prognosis. Attenuating or reversing remodeling is an accepted goal of heart failure therapy. Cardiac mechanical support with left ventricular assist devices, in addition to its established role as "bridge to transplantation" or "destination therapy" in patients not eligible for cardiac transplantation, offers the potential for significant and sustained myocardial recovery through reverse remodeling. This review discusses the emerging role of left ventricular assist devices as a "bridge to recovery". Clinical and basic aspects of cardiac remodeling and cardiac reverse remodeling enabled by mechanical unloading, potential candidates for this modality of treatment as well as unresolved issues regarding the use of mechanical circulatory support as a bridge to recovery are discussed. © 2008 Springer Science+Business Media, LLC

Loop diuretics for chronic heart failure: A foe in disguise of a friend?

Loop diuretics are recommended for relieving symptoms and signs of congestion in patients with chronic heart failure and are administered to more than 80% of them. However, several of their effects have not systematically been studied. Numerous cohort and four interventional studies have addressed the effect of diuretics on renal function; apart from one prospective study, which showed that diuretics withdrawal is accompanied by increase in some markers of early-detected renal injury, all others converge to the conclusion that diuretics receipt, especially in high doses is associated with increased rates of renal dysfunction. Although a long standing perception has attributed a beneficial effect to diuretics in the setting of chronic heart failure, many cohort studies support that their use, especially in high doses is associated with adverse outcome. Several studies have used propensity scores in order to match diuretic and non-diuretic receiving patients; their results reinforce the notion that diuretics use and high diuretics dose are true risk factors and not disease severity markers, as some have suggested. One small, randomized study has demonstrated that diuretics decrease is feasible and safe and accompanied by a better prognosis. In conclusion, until elegantly designed, randomized trials, powered for clinical endpoints answer the unsettled issues in the field, the use of diuretics in chronic heart failure will remain subject to physicians' preferences and biases and not evidence based. © Published on behalf of the European Society of Cardiology. All rights reserved

The challenge of treating congestion in advanced heart failure

Volume overload is a common manifestation of heart failure decompensation. Interaction between impaired renal and heart function constitutes an important pathophysiologic mechanism that leads to congestion. In addition to improving symptoms and volume status, reduction of rehospitalization rates, maintenance of renal function and improvement of survival are all important goals of every therapeutic strategy. Currently, the use of diuretics, vasodilators, inotropes and ultrafiltration, together with investigational agents such as oral vasopressin antagonists and adenosine A1-receptor antagonists, constitute the main therapeutic options for the congested heart failure patient. © 2011 Expert Reviews Ltd

Permanent Pacemaker Implantation in Patients with Persistent Left Superior Vena Cava

A world survey of 34 patients with persistent left superior vena cava who required permanent pacing is reviewed and one case of ours with dominant left superior vena cava is reported. Based on these cases, we conclude that the transvenous, rather than epicardial placement of a permanent pacemaker lead is the procedure of choice in patients with persistent left superior vena cava, with or without coexisting right superior vena cava. Copyright © 1990, Wiley Blackwell. All rights reserve