Insights from the Altshock-2 registry on intra-aortic balloon pump use in acute decompensated heart failure complicated by cardiogenic shock

Abstract Introduction and purpose intra-aortic balloon pump (IABP) is an ECG-gated, volume-displacement device that, while only modestly increasing cardiac output, significantly reduces left ventricle (LV) afterload. Acute decompensated heart failure (ADHF) cardiogenic shock (CS) is mechanistically characterized by a ventricular afterload mismatch. Cardiac output (CO) becomes highly sensitive to afterload changes and can improve significantly with its reduction by IABP. This study aimed to evaluate the outcomes of patients (pts) with ADHF-CS treated with IABP. Methods pts presenting with CS were consecutively enrolled between March 2020 and November 2023 in a multicenter cohort prospective study. We focused on ADHF-CS. Specific comparing tests were used for continuous variables, depending on their distribution, and for categorical variables. Kaplan–Meier and log-rank test were used for survival analysis. Multivariate logistic regression identified predictors of 60-day mortality. Results pts were categorized according to IABP use. A total of 189 ADHF-CS pts were analysed: 81 received IABP, 108 were treated with inotropes or other mechanical circulatory support (MCS) options, including Impella and ECMO. Baseline characteristics were similar between groups, except for age, kidney disease, left ventricular ejection fraction (LVEF) and heart transplant (HT) listing. The median time from Cardiac Intensive Care Unit (CICU) admission to IABP placement was 2 (IQR: 1.0-11.5) days, with a support duration of 168 hours (IQR: 94-438). Although not statistically significant, the complication rate was lower in the IABP group. Vasoactive agents were used in 95% of pts, with epinephrine being the most common in IABP group. Use of mechanical ventilation, renal replacement therapy, enteral nutrition and sedative drugs were similar. HT rate was higher in the IABP group, in-hospital mortality didn’t differ. IABP pts showed significantly better survival at 60 days, 6 months, and 1 year. Although pts in lower SCAI classes (A, B, and C) had better survival than those in advanced stages (D and E), there was a remarkable difference in the latter SCAI stages (D-E) amongst those not receiving and those receiving IABP (OR 6.5; CI: 1.6 - 26.4, p = 0.009). On univariate analysis, variables associated with 60-day mortality included age, atrial fibrillation, kidney disease, known cardiomyopathy, noradrenaline use, in-hospital cardiac arrest, SOFA and SAPS scores, and SCAI class. Although not statistically significant, IABP use showed a protective trend (p = 0.056). On multivariate analysis, mortality was linked to kidney disease, SCAI class, significant tricuspid regurgitation and in-hospital cardiac arrest. Conclusion IABP demonstrates potential as an effective support intervention in managing ADHF-CS including pts within advanced SCAI class stages. Further investigation is recommended to clarify its benefits in advanced cases.