Hemodynamic Response after Intra-Aortic Balloon Counter-Pulsation in Cardiac Amyloidosis and Cardiogenic Shock

Background In those with heart failure-related cardiogenic shock, intra-aortic balloon pump may improve hemodynamics and be useful as a bridge to advanced therapies. We explore whether those with cardiac amyloidosis and heart failure-related cardiogenic shock might experience hemodynamic improvement and describe the hemodynamic response after intra-aortic balloon pump. Methods We retrospectively identified consecutive patients with a diagnosis of cardiac amyloid, either light-chain or transthyretin, who were admitted to our intensive care unit with heart failure-related cardiogenic shock. Patients were excluded if intra-aortic balloon pump was placed during heart transplant or for shock related to acute myocardial infarction. Invasive hemodynamics before and after intra-aortic balloon pump placement were assessed. Results We identified 23 patients with cardiac amyloid who had an intra-aortic balloon pump placed for heart failure-related cardiogenic shock. One-year survival was 74% and most (65%) were bridged to heart transplant while one was bridged to destination left ventricular assist device. Following intra-aortic balloon pump, mean arterial pressure, cardiac index, and cardiac power index were significantly increased, while mean right atrial pressure, mean pulmonary artery pressure, and pulmonary capillary wedge pressure were all significantly reduced. Smaller left ventricular end diastolic diameter (per cm) was associated with higher likelihood of a cardiac index of < 2.2 L/min/m2 following intra-aortic balloon pump (OR 0.16, CI 0.01 – 0.93, P=0.04). Conclusion Intra-aortic balloon pump significantly improved cardiac index while reducing right atrial pressure, mean pulmonary artery pressure, and pulmonary capillary wedge pressure in CA patients with heart failure-related cardiogenic shock. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Dr. Joshua Longinow is supported by a grant from Pfizer for the research of transthyretin amyloidosis. Dr. Pieter Martens is supported by a grant from the Belgian American Educational Foundation (BAEF) and by the Frans Van de Werf Fund. Dr. Soltesz has received honoraria from ABIOMED, ABBOTT, and ATRICURE. Dr. Tang served as consultant for Sequana Medical, Cardiol Therapeutics, Genomics plc, Zehna Therapeutics, Renovacor, WhiteSwell, Kiniksa, Boston Scientific, and CardiaTec Biosciences and has received honorarium from Springer Nature and American Board of Internal Medicine. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This research study was approved by the Cleveland Clinic Institutional Review Board. Written informed consent was waived as all procedures were performed as part of routine clinical care. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedures. The authors had full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis, and may agree to make data available upon reasonable request. * CA : cardiac amyloidosis IABP : intra-aortic balloon pump HF : heart failure MCS : mechanical circulatory support ATTR-CA : transthyretin cardiac amyloidosis AL-CA : light chain cardiac amyloidosis CI : cardiac index CPI : cardiac power index PCWP : pulmonary capillary wedge pressure RAP : right atrial pressure mPAP : mean pulmonary artery pressure HF : heart failure CS : cardiogenic shock