The role of intraaortic balloon counterpulsation in patients undergoing cardiac operations

Percutaneous intraaortic balloon pumping: four years from Tiblisi

Intraaortic balloon pumping (IABP) has now evolved as the mechanical supportive treatment of choice for the management of refractory left ventricular power failure. A new single-chambered percutaneous intraaortic balloon (Datascope Corp., Paramus, NJ, U.S.A.) has been constructed around a central guidewire. The balloon can be wrapped around the guidewire, enabling its insertion into the femoral artery through a 12-F sheath, inserted by a modified Seldinger technique. A dual-lumen automatic wrapping version has recently been employed. Percutaneous IABP insertion has been performed in 149 patients (mean age 58 years). In our medical group of 75 patients, 59 underwent urgent open heart surgery and 53 (90%) survived. In patients who could not be separated from cardiopulmonary bypass, 23 of 61 (38%) survived. Vascular complications occurred in 10% of the patients. Percutaneous balloon insertion permits the rapid institution of IABP support and broadens the medical and surgical applications of IABP.

A technique for immediate manual external aortic counterpulsation during cardiac surgery

Intraaortic balloon pump counterpulsation is well established as a lifesaving measure. Aortic counterpulsation may be achieved externally as well as internally. A simple technique for manual external aortic counterpulsation during cardiovascular surgical procedures is presented. This technique is available on immediate demand and identical in effect to intraaortic balloon pumping, and it may be lifesaving in patients with acute cardiovascular decompensation since it allows time for institution of necessary emergency therapy.

Accelerated renovascular hypertension following intra-aortic balloon counter-pulsation

A 62-year-old man developed high serum renin arterial hypertension following thoraco-abdominal dissection which resulted from insertion of an intra-aortic balloon pump (IABP). Nephrectomy resulted in cure of medically unmanageable hypertension.

Mechanical techniques of circulation support: a percutaneous intra-aortic balloon device

As medical indications for intra-aortic balloon (IAB) pumping expand, many physicians without surgical expertise are faced with the decision to institute circulatory support. Accordingly, to facilitate rapid establishment of cardiac assist and to obviate the need for operative insertion and removal, a 40-cc single-chambered device was designed for percutaneous insertion by the Seldinger technique. Hemodynamic augmentation produced by the percutaneous balloon is similar to that obtained with conventional IAB. It appears that complications related to IAB insertion may be decreased by the percutaneous method.

Paraplegia following balloon assistance after cardiac surgery

Contrapulsation by means of an intra-aortic balloon is an effective and well-known therapeutic measure in the postoperative period after cardiac surgery, mainly when interrupting cardiopulmonary bypass in left ventricular failure situation (3, 4). We present the case of a patient who developed paraplegia 38 hours after surgery, which was attributed to contrapulsation.

Improved technique of intraaortic balloon insertion

Routine insertion of an intraaortic balloon through the femoral artery may be difficult in the face of obstructive aortoiliac atherosclerosis. Perioperatively, the balloon catheter may be guided through diseased vessels by transabdominal palpation.

Paraplegia following intraaortic balloon assistance

In a patient receiving intraaortic balloon counterpulsation following myocardial revascularization, paraplegia developed two days post-operatively. Postmortem examination demonstrated a dissecting hematoma of the thoracic aorta and spinal cord infarction. The neurological deficit is thought to be due to embarrassment of spinal cord blood supply, and mechanisms of injury are discussed.

Results and complications of intraaortic balloon pumping in surgical and medical patients

The intraaortic balloon was attempted for therapy in 94 patients and successfully placed in 86. The balloon catheter could not be passed through the femoral or iliac artery in 12 patients (13 percent) of the group; in 4 of these the balloon was inserted through an aortic arch graft. The medical indications were cardiogenic shock and preinfarction angina. Ten of the 14 patients in the group with shock survived when treated with an aortic balloon without emergency surgery. Indications for balloon pumping in the surgical group included inability to wean the patient from the pump-oxygenator, postoperative shock and prophylactic placement of the balloon for poor ventricular function. Inability to remove a patient from pump-oxygenator support was the most common surgical indication, and 47 percent of patients were long-term survivors. Only 1 of the 17 patients for whom balloon pumping was used prophylactically died. Complications occurred in 17 percent of the entire group of 86 patients although the rate for medical patients with cardiogenic shock was 50 percent. The most common complication was arterial insufficiency requiring removal of the balloon. Four patients had permanent damage to the legs from ischemia, one patient requiring bilateral amputation. The overall incidence of serious arterial obstruction was 10 percent. Other complications included balloon displacement with arterial obstruction and pericardial tamponade from anticoagulant agents resulting in death.

Preoperative intra-aortic balloon assist in high risk revascularization patients

Sixty-five high risk myocardial revascularization patients had preoperative IABP with two operative deaths. Only six patients needed rapid institution of cardiopulmonary bypass after anesthesia induction despite marked blood pressure drop in half the patients. There were only two instances of postpump power failure. Preoperative IABP is a valid method of limiting morbidity associated with coronary surgery in high risk patients.

Preoperative intra-aortic balloon support in surgery for left main coronary stenosis

Twenty-six patients with left main coronary (LMC) stenosis were operated upon with preoperative intra aortic balloon pump (IABP) support. There was no mortality, and no morbidity attributable to the balloon catheter. The most delicate facet of revascularization surgery in this entity is the pre-cardiopulmonary bypass phase including anesthesia induction during which blood pressure fluctuation may further diminish severely compromised coronary flow. Although systolic pressure dropped to below 100 mm Hg in 50% of patients during induction, there were only two patients with electrocardiographic evidence of perioperative myocardial infarction, and only one who needed rantic institution of cardiopulmonary bypass just after induction. Perioperative logistics were quite trouble free in all 26 patients, in marked contrast to 5 LMC patients operated upon prior to our preoperative IABP concent; 3 of these deteriorated upon induction, with two deaths resulting. Preoperative IABP is a reasonable supportive adjunct in surgery for LMC stenosis.

Methods and results of mechanical myocardial support

In recent years the development of modern direct techniques for revascularization surgery has resulted in a multitude of critically ill patients undergoing open heart surgery. To deal with the increasing numbers of patients who both require urgent open heart surgery and present with many complicated patterns of disease, a spectrum of cardiac assist measures, ranging from simple pharmacological interventions to mechanical cardiac assist techniques, has been developed. Those temporary mechanical cardiac assist devices which employ the principle of couterpulsation and balloon pummping have met with the most consistent clinical success. We now report our experience and progress in this field since early 19729

Intraaortic balloon assistance

Intraaortic balloon (IAB) assistance in 64 patients over 2 1/2 years has resulted in a survival rate of 11% (1 patient) when used alone but 47% when utilized in patients treated surgically (long-term survival, 38% [21 patients]). Patients undergoing coronary artery bypass grafting or aortic valve replacement have a long-term survival of 50% (8 and 9 patients, respectively). The required duration of IAB support has a bearing on the clinical result. Complications have been minimal. Though it was originally developed to assist in the nonoperative management of complications of ischemic heart disease, IAB assistance offers significant promise as an adjuvant to operative therapy for both ischemic and valvular heart disease.