Sub-análisis del IABP_SHOCK II trial La primera publicación del balón intraaórtico de contrapulsación (BIAC) fue en mayo de 1962 en la American Heart Journal (1) desarrollada comercialmente entre los años 1967 a 1969 por el cirujano cardiovascular Dr. William Rassman, en el Cornell Medical Center y fabricada por la Datascope Corporation en 1969. La primera vez fue usado en
Sub-análisis del IABP_SHOCK II trial
La primera publicación del balón intraaórtico de contrapulsación (BIAC) fue en mayo de 1962 en la American Heart Journal (1) desarrollada comercialmente entre los años 1967 a 1969 por el cirujano cardiovascular Dr. William Rassman, en el Cornell Medical Center y fabricada por la Datascope Corporation en 1969.
La primera vez fue usado en una mujer de 48 años en choque cardiogénico, que no respondía al tratamiento convencional, en uso por 6 horas y con suceso en el Maimonides Medical Center, Brooklyn, N.Y. en junio de 1967 por los doctores Dr. Adrian Kantrowitz and Dr. Steven Phillips.
Desde entonces han sido muchas las publicaciones en relación al empleo del BIAC.
En estos más de cincuenta años, el entendimiento del choque cardiogénico, sus mecanismos, las conductas en un infarto agudo de miocardio con supradesnivel del segmento S-T, la llegada de terapias farmacológicas y hemodinámicas, han cambiado la perspectiva del uso del BIAC.
El artículo publicado por la Sociedad Europea de Cardiología (mayo 2020) sobre el impacto del momento de la colocación del balón de contrapulsación aórtico en el choque cardiogénico- un sub-análisis del IABP_SCHOCK II trial (Impact of timing of intraaortic ballon counterpilsation on mortality in cardiogenic shock – a subanalysis of the IABP-SHOCK II TRIAL) intenta responder la pregunta: si el «momento» de la colocación del balón antes o después de angioplastia en el infarto agudo de miocardio puede influir el choque cardiogénico y consecuente mortalidad.
¿Será que el implante precoz antes de la angioplastia mejoraría la perfusión miocárdica, el tamaño del infarto y por lo tanto mejoraría las condiciones para la angioplastia y reduciría la severidad del choque cardiogénico y consecuente mortalidad?
Fig 1. Flujo de estudio.
IAPB: balón intraaórtico de contrapulsación; PCI: intervención coronaria percutánea
Este ya conocido estudio de 600 pacientes en choque cardiogénico (fig.1), de los cuales 275 fueron a para intervención percutánea con asistencia de BIAC y de los cuales 33 el balón fue implantado antes de la intervención y 242 después. Con el primer objetivo de mortalidad en 30 días (fig 2) y objetivos secundarios como mortalidad en 6 meses, un año, niveles de lactato sanguíneo en las primeras 48 horas, complicaciones que incluía accidentes vasculares cerebrales o periféricos, nuevo infarto y soporte circulatorio o renal llegando a la siguiente conclusión:
-El momento del implante del BIAC no tuvo impacto en la mortalidad a corto y largo plazo en pacientes con infarto agudo de miocardio complicado por choque cardiogénico, así con los objetivos secundarios no mostraron diferencias entre los pacientes que usaron balón antes o después de la intervención. (fig 2)
Fig 2 Mortalidad por todas las causas a largo plazo.
IC: intervalo de confianza; HR: índice de riesgo; BCIA: bomba de balón intraaórtico; PCI: intervención coronaria percutánea
El balón de contrapulsacion aórtica es usado en tres circunstancias, la primera en aquellos pacientes con infarto agudo de miocardio inestables que serán sometidos a una coronariografía que determinará un tratamiento con angioplastia o revascularización, en segundo caso aquellos pacientes en choque cardiogénico que no responde a terapia medicamentosa o como puente a otras terapias, y finalmente y raramente: aquellos con angina refractaria que esperan la revascularización.
Desde el inicio fue difícil randomizar un gran grupo de pacientes, los trabajos generalmente fueron observacionales. Las variables de un paciente que llega una emergencia con un gran infarto que lo llevará a un choque cardiogénico son muchas, pueden ir desde el perfil del paciente, el tiempo de reperfusión, anatomía coronaria, sitios de obstrucción y tiempo de isquemia, que influyen en el desarrollo y la evolución hacia un choque cardiogénico.
En las directrices europeas de tratamiento del infarto agudo de miocardio está con indicación IIa (Ref. 6). En ambientes donde llegar a una sala de hemodinámica son cada vez mejores y donde las evidencias van mostrando que la presencia del balón intraaórtico de contrapulsación será menos frecuente.
Todo esto nos lleva a pensar que el momento de la colocación de este dispositivo será más una variable que puede ayudar, pero está lejos de ser determinante en influir en la mortalidad.
Ver link AQUI
Referencias:
1:American Heart Journal of May 1962; 63: 669-675 by S. Moulopoulos, S. Topaz and W. Kolff.
2.Impact of timing of intraaortic ballooncounterpulsation on mortality in cardiogenic shock – a subanalysis of the IABP-SHOCK II trial European Heart Journal: Acute Cardiovascular Care 0(0) 1–8 The European Society of Cardiology 2020
3 Katz, NR Smilowitz, JS Hochman: Another Nail in the Coffin for Intra-Aortic Balloon Counterpulsion in Acute Myocardial Infarction With Cardiogenic Shock.Circulation. 139(3): 404-406. 2019 Jan 15. 30586784
4. H Thiele, U Zeymer, N Thelemann, et al: Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction: Long-Term 6-Year Outcome of the Randomized IABP-SHOCK II Trial. 2018 Nov 11. [Published online ahead of print] 30586721
5.H Thiele, et al.: Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 367 (14):1287-1296 2012 22920912
6.2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation European Heart Journal, Volume 39, Issue 2, 07 January 2018, Pages 119–177, https://doi.org/10.1093/eurheartj/ehx393
Published: 26 August 2017
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