Response to the editorial titled "BVS, RDN, IABP: The Afghanistan of interventional clinical trials.

The Editor,

We read your editorial article titled “BVS, RDN, IABP - The Afghanistan of interventional cardiology trials with great interest. You have provided us with a great insight into the understanding of the failure of these highly anticipated therapies in their respective pathologies. We agree that these therapies like biovascular scaffold (BVS) and renal denervation (RDN) were launched into the market in a haste and hype was created earlier than evidence was provided for their beneficial role. But we would like to differ in the inferrence of conclusion about intra aortic balloon pump (IABP) in cardiogenic shock. In our setting, IABP is the one of most important tool in the management of cardiogenic shock other than revascularization. The reason for failure of IABP SHOCK II was probably because the etiology of cardiogenic shock is multifactorial IABP supports only one aspect of the cardiogenic shock by decreasing the afterload to the heart and increasing the diastolic blood flow in the coronaries. Patients presenting >12 h were excluded in this trial, these are the most high risk patients and these patients are more likely to benefit from IABP because management of these patients will not only be revascularization but also myocardial stabilization as shown in studies involving strain imaging. Along with right ventricular myocardial infarction patients, a significant number of patients with LV dysfunction and cardiogenic shock have a component of fluid responsiveness and these patients are better managed by giving fluid therapy based on IVC diameter. So blindly putting IABP in all patients with cardiogenic shock will neutralize the beneficial results, as it occurred in the IABP SHOCK II trial. Rather IABP insertion should be done in high risk cardiogenic shock patients like late presenters, with severe left ventricular dysfunction, critical Left main/triple vessel disease, then only we can show a beneficial role of these mechanical circulatory device in cardiogenic shock patients. Sicker the patient, more likely is the benefit of IABP.