Percutaneous left axillary artery placement of an intra-aortic balloon pump (IABP) was found to be safe and effective for patients with advanced heart failure, according to study results published in JACC: Heart Failure.
In patients who require prolonged mechanical circulatory bridge support (MCS), the placement of IABP transfemorally reduces mobility and ambulation, which can lead to increased risks for infection and debilitation. The alternative axillary approach has less impact on mobility compared with the femoral strategy.
In this retrospective study, the data of 195 patients with advanced heart failure (mean age, 58.2±10.1 years; 79.5% men) who underwent ultrasound-guided percutaneous axillary IABP placement between November 2007 and June 2018 at a single center were examined. The 2 outcomes post-IABP were successful cardiac replacement with heart transplant or left ventricular assist device (LVAD) implantation, or failed cardiac replacement (ie, death, IABP removal, or unplanned MCS upgrade). Clinical and hemodynamic parameters were compared in the successful and failed cardiac replacement groups, and adverse events experienced during MCS were reported.
At baseline, 58.5% of patients had nonischemic cardiomyopathy. The median duration of IABP support was 19 days (interquartile range, 12-43 days). A total of 133 participants (68.2%) had successful cardiac replacement (120 heart transplants, of which 22% were dual-organ transplants; 13 LVAD implantation) and 62 patients (31.8%) had failed cardiac replacement. There were 18 patients (9.2%) who required support escalation, 16 patients (8.2%) who died on IABP support, and 28 patients (14.4%) who required IABP removal.
Overall, transfemoral placement of IABP was associated with improved end-organ function. Several variables were found, in a multivariate analysis, to be associated with death after transfemoral IABP placement: higher right atrial/pulmonary capillary wedge pressure ratio (adjusted odds ratio [OR], 50.08; 95% CI, 3.46-724.79; P =.004), decreased left ventricular end diastolic dimension (OR, 0.46; 95% CI, 0.23-0.92; P =.027), and ischemic cardiomyopathy diagnosis (OR, 7.15; 95% CI, 1.05-48.75; P =.045).
In successfully bridged patients, 1-year survival rates were 87% post-transplant and 62% post-LVAD implantation. Despite frequent bedside repositioning, device malfunction necessitated replacement in 72 patients who received IABP (36.9%). A minority of patients experienced vascular complications, with left upper extremity ischemia, cerebrovascular accident and mesenteric ischemia occurring in 3.5%, 2.5% and 3% of patients, respectively.
Study limitations include its retrospective design and single-center setup.
“For patients who do not need greater mechanical support, axillary percutaneous IABP can be used safely with a lower adverse event profile,” noted the authors.
Funding and Conflicts of Interest Disclosures
Dr Bhimaraj is a consultant for Abbott and Abiomed. Dr Guha serves on the Speakers Bureau for Abbott. Dr Estep is a consultant for Maquet Getinge Group and Abbott; and serves on the Medical Advisory Board for Medtronic Inc.
Bhimaraj A, Agrawal T, Duran A, et al. Percutaneous left axillary artery placement of intra-aortic balloon pump in advanced heart failure patients. JACC Heart Fail. 2020;8(4):313-323. doi:10.1016/j.jchf.2020.01.011