EComment. Re: Is heparin needed for patients with an intra-aortic balloon pump?

Abstract

The article by Pucher et al. [1] showed the expected results of heparin need for patients with an intra-aortic balloon pump (IABP). At the same time, they observed that the use of heparinization with IABP, which was intended to reduce the risk of thrombus, thromboembolus or limb ischaemia, will concomitantly increase the risk of bleeding as a side-effect. They therefore concluded from the studies that omitting or implementing a selective use strategy of heparinization during IABP counterpulsation could significantly decrease the incidence of bleeding without an increase in limb ischaemic events[1]. It is important to state that the use of IABP showed be holistic, especially when considering ischaemic complications such as limb ischaemia. While it is true that judicious use of an adjunct like heparin should be seriously considered in light of the attendant complications, the physical properties of the IAPB should also be seriously considered vis a vie the size of the balloon/catheter and sheathless technique. In particular, the height/ body surface area of the patients should be taken into account to avoid the occlusive effect of the balloon/catheter, which can lead to an increased effect of limb ischaemia. Scholz et al. observed that using thinner catheters for percutaneous placement was associated with a reduction in the rate of complications, from 20.7 % (17 of 82 patients) for 12 French catheters to 9.9 % (10 of 101 patients) for 10.5 French catheters (P= 0.04), and 8.4 % (14 of 167 patients) for 9.5 French catheters (P = 0.006) and with multivariate logistic regression analysis identified catheter size (odds ratio 3.4 for 12 French catheters) and other factors were independent risk factors for counterpulsation-associated complications[2]. Nash et al., whilst stating that IABP was helpful for controlling myocardial ischaemia and providing haemodynamic support, pointed out that its applicability was limited by lower extremity ischemic complications in a significant percentage of patients. They developed a new sheathless technique for percutaneous intra-aortic balloon catheter insertion, which reduced the effective catheter size. A pilot study conducted using this new technique resulted in a 10% rate of limb ischemia, without compromise of balloon function. They concluded that the technique was useful in reducing the incidence of limb ischaemia associated with IAPB [3]. Thus in the use of IAPB, especially when heparinization is to be discouraged or omitted for fear of bleeding, the balloon/catheter size, and possibly the avoidance of a sheath should be considered. Conflict of Interest: None declared