Response to Letter Regarding Article, “Visceral Arterial Compromise During Intra-Aortic Balloon Counterpulsation Therapy”

Abstract

HomeCirculationVol. 123, No. 18Response to Letter Regarding Article, “Visceral Arterial Compromise During Intra-Aortic Balloon Counterpulsation Therapy” Free AccessReplyPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReplyPDF/EPUBResponse to Letter Regarding Article, “Visceral Arterial Compromise During Intra-Aortic Balloon Counterpulsation Therapy” Ardawan Julian Rastan, Eugen Tillmann and Sreekumar Subramanian Lukas Lehmkuhl Anne Kathrin Funkat, Sergej Leontyev, Torsten Doenst and Thomas Walther Matthias Gutberlet Friedrich Wilhelm Mohr Ardawan Julian RastanArdawan Julian Rastan Search for more papers by this author , Eugen TillmannEugen Tillmann Search for more papers by this author and Sreekumar SubramanianSreekumar Subramanian Search for more papers by this author Lukas LehmkuhlLukas Lehmkuhl Search for more papers by this author Anne Kathrin FunkatAnne Kathrin Funkat Search for more papers by this author , Sergej LeontyevSergej Leontyev Search for more papers by this author , Torsten DoenstTorsten Doenst Search for more papers by this author and Thomas WaltherThomas Walther Search for more papers by this author Matthias GutberletMatthias Gutberlet Search for more papers by this author Friedrich Wilhelm MohrFriedrich Wilhelm Mohr Search for more papers by this author Originally published10 May 2011https://doi.org/10.1161/CIRCULATIONAHA.110.016154Circulation. 2011;123:e589With great interest, we read the letter from Dr Michael Poullis concerning our recently published article on the adverse effects of intra-aortic balloon pump (IABP) malposition and anatomic-to-device mismatch on visceral organ function.1First, with respect to IABP position, we defined the correct proximal position of the tip as 1 to 2 cm distal to the left subclavian artery origin because this position is generally taught, and it is recommended by the IABP manufacturers. Although there may be a rationale for an alternative position, no scientific data exist to support alternative positioning. Therefore, our analysis was based on the gold standard of IABP position.Second, we agree that high-quality transesophageal echocardiography in particular, when done by experienced clinicians, allows for identification of celiac trunk coverage and appropriate balloon adjustment.2 However, in most institutions, this is not a standard assessment. Perhaps this discussion will serve to increase the use of transesophageal echocardiography to assess distal balloon position. At the same time, it should be noted that transesophageal echocardiography is powerless to compensate for a balloon that is too long anatomically.Finally, we agree that, in aortas with sufficient transverse diameter, the issue of a diastolic malperfusion may not be clinically relevant. However, we had speculated in our article that, in patients with small aortas, complete aortic occlusion may potentially lower the overall visceral artery perfusion, even if systolic perfusion is unaffected.Finally, we agree that visceral artery compromise during IABP support is generally only a cofactor for the development of visceral ischemic complications in these critically ill patients with vasopressor requirements, low output syndrome, and intermittent hypotension. However, IABP support was recently found to be an independent risk factor for acute kidney injury after coronary artery bypass surgery,3 and may have a more direct role in visceral ischemic complications than previously believed. The major aim of our study was to demonstrate that the combination of a low balloon position and anatomic-to-device length mismatch occur frequently in clinical practice and can induce diastolic vascular obstruction or debris embolization. It is hoped that this will serve to remind clinicians of the role that the IABP may play in unexpected visceral malperfusion syndromes.Ardawan Julian Rastan, MD, PhDEugen Tillmann, MDSreekumar Subramanian, MD Department of Cardiac Surgery Heart Center University of Leipzig Leipzig, GermanyLukas Lehmkuhl, MD Department of Radiology Heart Center University of Leipzig Leipzig, GermanyAnne Kathrin Funkat, PhDSergej Leontyev, MDTorsten Doenst, MD, PhDThomas Walther, MD, PhD Department of Cardiac Surgery Heart Center University of Leipzig Leipzig, GermanyMatthias Gutberlet, MD, PhD Department of Radiology Heart Center University of Leipzig Leipzig, GermanyFriedrich Wilhelm Mohr, MD, PhD Department of Cardiac Surgery Heart Center University of Leipzig Leipzig, GermanyDisclosuresNone.