Percutaneous Intra-aortic Balloon Research Articles

Abstract 305: Contemporary Analysis of Percutaneous Intraaortic Balloon Pump Therapy as a Bridge to Orthotopic Heart Transplant

Objective: Intra-aortic balloon pump (IABP) support has been used as a bridge to transplant (BTT) therapy for acutely deteriorating patients awaiting orthotopic heart transplantation (OHT). Given recent changes to the heart allocation algorithm which have expanded IABP use for BTT, the evaluation of device strategy, complications, and near-term survival is warranted. Methods: Patients bridged with IABP who underwent OHT between October 2018 and January 2020 at our institution were retrospectively reviewed (n=21). Chart review was conducted to assess IABP insertion site, timing of support, device-related complications, removal strategy, and thirty-day post-transplant mortality. Results: Patients were bridged with femoral (n=6), axillary (n=9), or femoral with axillary conversion (n=6) approaches for IABP insertion. Common complications included pump malposition (n=5), hematuria (n=4), pump exchange (n=9), and insertion site bleeding (n=2). Median duration of IABP support was 12 [7, 18] days and median time to removal after OHT was 1 [1, 2] day. IABP removal occurred at the bedside with direct pressure application for all femoral pumps (n=6). Among axillary pumps (n=15), 11 were removed at the bedside with direct pressure, 3 were removed in the operating room, and 1 was removed in the catheterization lab with device closure. There was no thirty-day mortality following OHT. Conclusion: Following the changes to the heart allocation algorithm, IABP has become the most common method of temporary mechanical circulatory support for patients awaiting OHT at our center with excellent early survival and acceptable complication rates. In addition to allowing patients to ambulate while on IABP, we find that axillary insertion did not result in excess bleeding complications and that bedside removal with direct pressure was a safe method for postoperative decannulation.

Comparison of Percutaneous Ventricular Assist Device and Intra-Aortic Balloon Pump for Cardiogenic Shock

Purpose Over the past decade, novel temporary percutaneous ventricular assist devices (PVAD) have emerged with active continuous flow support for the management of cardiogenic shock. The hemodynamic benefit of PVADs over the intra-aortic balloon pump (IABP) is established. However, data comparing the clinical use and outcomes of these devices have been sparse and controversial. Methods A single center, retrospective chart review was performed on adult patients who required temporary mechanical support with an IABP or PVAD (Abiomed Impella 5.0, Danvers, MA) for at least 72 hours in duration for the management of refractory, acute cardiogenic shock. These patients were adjudicated to have cardiogenic shock defined by cardiac index (CI) Results 43 patients met inclusion requirements for this study, with 28 patients receiving a PVAD and 15 patients receiving an IABP. Age, sex, ethnicity, and baseline hemodynamics were similar. Baseline serum creatinine (Cr) was higher in PVAD vs IABP (2.3 vs 1.6 mg/dL; p=0.033). Following intervention, PVAD had a higher likelihood for successful bridge to Tx/VAD compared to IABP (p=0.003). Both modalities showed similar 30-day mortality (Figure 1, p=0.26). Cardiac index improved for both PVAD and IABP. Renal function improved only after PVAD (Cr, 2.4 vs 1.8 mg/dL; p=0.02). Non-fatal bleeding was higher with PVAD. Conclusion In this single center study, PVAD was associated with more successful bridge to Tx/VAD, improved PCWP, CI and end-organ function. There was a trend towards higher survival compared to IABP albeit with a higher incidence of minor bleeding complications. Further studies are needed to distinguish the benefits of PVAD therapy.

Successful use of percutaneous ECMO and intra-aortic balloon support for a rescue valve in valve TAVR procedure in a patient in cardiogenic shock

Successful use of percutaneous ECMO and intra-aortic balloon support for a rescue valve in valve TAVR procedure in a patient in cardiogenic shock

Rupture of the Anterolateral Papillary Muscle Caused by a High Lateral Branch Occlusion

Although necrosis of the left ventricular papillary muscles during acute myocardial infarction is common, rupture of the anterolateral papillary muscle due to occlusion of high lateral branch is rare. We present a rare case of anterolateral papillary muscle rupture caused by occlusion of a high lateral branch of the left coronary artery. Although the patient was in cardiogenic shock on admission, she was successfully treated by emergency mitral valve replacement after percutaneous catheter intervention and intra-aortic balloon pumping support. This case implies that the anterolateral papillary muscle can have a single blood supply and that it can be ruptured by an occlusion of a high lateral branch. Prompt diagnosis, immediate mechanical stabilization and aggressive surgical treatment are essential to save this group of patients.

Intra-aortic balloon pump associated vascular complications in cardiac surgical patients: the past and the future

Background Despite low profile and percutaneous insertion intra-aortic balloon pumps (IABP) are prone to local vascular complications with important impact on outcome in cardiac surgery patients. The aim of this study was to evaluate number and sort of vascular complications related to IABP insertion within a 12-year period.

Percutaneous Placement of an Intra-Aortic Balloon Pump in the Left Axillary/Subclavian Position Provides Safe, Ambulatory Long-Term Support as Bridge to Heart Transplantation

This study evaluated the feasibility, tolerability, and efficacy of a strategy for percutaneous intra-aortic balloon pump (IABP) placement through the left axillary-subclavian artery to provide mechanical circulatory support in patients with end-stage heart failure as a bridge to heart transplantation. The transfemoral approach to IABP placement is associated with major disadvantages, including the risk for infection and limitation of patient mobility in those requiring extended support. We developed a percutaneous technique for placing IABPs in the left axillary artery that permits upright sitting and ambulation. We performed a retrospective review of data from patients who had undergone left axillary IABP implantation between 2007 and 2012. Fifty patients who received a left axillary IABP as a bridge to transplantation were identified, of whom 42 (84%) underwent heart or heart-multiorgan transplantation. Cumulative survival on IABP support was 92%, and post-transplant 90-day survival was 90%. Median duration of support was 18 days. Four of 50 patients (8%) died while on IABP support, and 3 (6%) received greater mechanical circulatory support. Four patients (8%) had clinically significant thromboembolic or bleeding events without long-term sequelae. The most common minor adverse event was IABP malposition, in 22 patients (44%). Prolonged IABP support in the heart-transplantation cohort was associated with significant improvements in mean pulmonary artery pressure and in creatinine and total bilirubin concentrations. Percutaneous insertion of an IABP through the left axillary artery is a feasible and relatively well-tolerated strategy to bridge patients with end-stage heart failure to heart transplantation. This form of mechanical-device treatment permits upright sitting and ambulation in those requiring extended support.

Abstract 195: Length of Stay in High Risk Percutaneous Coronary Intervention in US: A 5 year Contemporary Experience

Background: High Risk Percutaneous Coronary Intervention (PCI) is increasingly being performed with the availability of hemodynamic support. The aim of this study was to determine the predictors of length of stay (LOS) for high risk PCI in US. Methods: We explored the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) using the ICD9 procedure code of 36.07 and 36.06 for PCI. NIS is largest all-payer dataset that represents 20% of all US hospitals. We included patients who had PCI from 2005 through 2010 who also underwent Percutaneous Circulatory Assist Device (PCAD) or Intra-aortic Balloon Pump (IABP) placement during the same hospital admission. Severity of comorbidities was defined by Deyo modification of Charlson’s Comorbidity Index (CCI). Hospitals were identified by a unique hospital identification number and hospital volume was determined by calculating the total number of PCI performed by an institution on year to year basis. Complications were based on Patient Safety Indicators (PSI) recognized by Agency for Health Care Research and Quality to monitor in hospital complications. We examined the predictors of LOS by a mixed effects linear regression model including patient demographics, admission characteristics, CCI quartiles with first quartile as a reference, hospital PCI volume quartiles, IABP or PCAD use and periprocedural complications. Hospital ID was incorporated as random effects in the model. Results: A total of 26,300 High Risk PCIs (weighted n = 130,151) were available for analysis. Factors associated with increased LOS were the use of IABP as compared to PCAD (+0.86 days, p=0.03), occurrence of any complication (+4.67 days, P < 0.001), high CCI (+2.5 days for CCI=2 and +4.1 days for CCI≥3, p<0.001 for both), teaching hospital (+0.96 days, p <0.001), presence of myocardial infarction (MI) or shock (+0.55 days, p = 0.002) and highest quartile of hospital PCI volume (+0.86 days, p<0.001). Factors associated with decreased LOS included private insurance (-0.9 days, p < 0.001) and self-pay or no insurance (-0.89 days, p<0.001). Conclusion: In our observational study based on a large database, use of IABP as compared to PCAD, occurrence of complications, CCI, teaching hospital, presence of MI or shock and high PCI volume were associated with increased LOS & having private insurance and self pay or no insurance was associated with decreased LOS.

TCT-68 The use of Percutaneous Left Ventricular Assist Device vs Intra-aortic Balloon Pump for Hemodynamic Support During High Risk PCI

Protect II study evaluated the effect of circulatory support with Impella vs Intra aortic balloon pump (IABP) in high risk patients undergoing high risk PCI with depressed LV function and complex anatomy. The results of the study were confounded by an imbalanced and more vigorous use of rotational

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

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

Comparison of Hospital Mortality With Intra-Aortic Balloon Counterpulsation Insertion Before vs After Primary Percutaneous Coronary Intervention for Cardiogenic Shock Complicating Acute Myocardial Infarction

Abstract. Primary percutaneous coronary intervention (PCI) and intra-aortic balloon pump counterpulsation (IABP) are established treatment modalities in acute myocardial infarction complicated by cardiogenic shock. We hypothesized that the insertion of the IABP before primary PCI might result in better survival of patients with cardiogenic shock compared with postponing the insertion until after primary PCI. We, therefore, retrospectively studied 48 patients who had undergone primary PCI with IABP because of cardiogenic shock complicating acute myocardial infarction (26 patients received the IABP before and 22 patients after primary PCI). No significant differences were present in the baseline clinical characteristics between the 2 groups. The mean number of diseased vessels was greater in the group of patients treated with the IABP before primary PCI (2.8±0.5 vs 2.3±0.7, P=.012), but the difference in the number of treated vessels was not significant. The peak creatine kinase and creatine kinase-MB levels were lower in patients treated with the IABP before primary PCI (median, 1077; interquartile range, 438–2067 vs median, 3299; interquartile range, 695–6834; P=.047 and median, 95; interquartile range, 34–196 vs median, 192; interquartile range, 82–467; P=.048, respectively). In-hospital mortality and the overall incidence of major adverse cardiac and cerebrovascular events were significantly lower in the group of patients receiving the IABP before primary PCI (19% vs 59% and 23% vs 77%, P=.007 and P=.0004, respectively). Multivariate analysis identified renal failure (odds ratio, 15.2; 95% confidence interval, 3.13–73.66) and insertion of the IABP after PCI (odds ratio, 5.2; 95% confidence interval, 1.09–24.76) as the only independent predictors of in-hospital mortality. In conclusion, the results of the present study suggest that patients with cardiogenic shock complicating acute myocardial infarction who undergo primary PCI assisted by IABP have a more favorable in-hospital outcome and lower in-hospital mortality than patients who receive IABP after PCI. Abdel-Wahab M, Saad M, Kynast J, et al. Comparison of hospital mortality with intra-aortic balloon counterpulsation insertion before versus after primary percutaneous coronary intervention for cardiogenic shock complicating acute myocardial infarction. Am J Cardiol. 2010;105:967–971.

Treatment of iatrogenic false aneurysms.

The incidence of iatrogenic false aneurysms has risen exponentially in recent years. Although this growth in peripheral vascular injuries likely is multifactorial in origin, the increasing complexity of percutaneous techniques combined with public demand for minimally invasive procedures has probably contributed. Periprocedural complications secondary to vascular interventions include false aneurysms, hematomas, thromboemboli, AV fistulae, and lacerations. False aneurysms, or pseudoaneurysms, account for more than 60% of these iatrogenic complications. Historically, the incidence of procedure-related vascular injury has been estimated as 0.05% to 0.1%. Today the incidence is estimated to range from 0.2% to 9.0%. Although percutaneous vascular access was once primarily used for diagnostic purposes, a transfemoral approach is now used for a wide variety of both diagnostic and therapeutic modalities. The femoral route is generally preferred for ease and reliability of access to the arterial and venous systems. Consequently, iatrogenic vascular injuries and false aneurysms are frequently located in the groin. The terms false aneurysm, pseudoaneurysm, and pulsatile or communicating hematoma are synonymous and may be used interchangeably. True aneurysms are defined as a circumscribed dilation of the artery; pseudoaneurysms involve dilation of an artery with actual disruption of one or more layers of its walls. The etiology of true and false aneurysms also differs: true aneurysms are typically caused by degenerative factors and false aneurysms are generally traumatic in origin. Iatrogenic pseudoaneurysms are most commonly produced by cardiac catherization, and these diagnostic and interventional procedures account for 70% to 80% of the incidence. Peripheral angiography or angioplasty, or both, are responsible for 10% to 15% of pseudoaneurysms. Additional causes of iatrogenic false aneurysms include percutaneous hemodialysis access, percutaneous intraaortic balloon pump placement, and other interventional techniques. Risk factors for the development of iatrogenic pseudoaneurysms include age greater than 60 years, female gender, catheter size greater than 8F, cannulation of both artery and vein, and concurrent anticoagulation. Operator inexperience, catherization of an artery other than the common femoral artery, and underlying peripheral vascular disease are also positively correlated with increased risk of false aneurysm formation. The natural history of peripheral vascular injuries is uncertain and surgical dictum previously mandated prompt operative repair. Recently, the focus has shifted from open surgical repair to a vast array of management options, including observation, compression therapies, thrombin injection, and embolization procedures. The remainder of this review focuses on the diagnosis, natural history, and treatment options for iatrogenic false aneurysms.

Complications of intra-aortic balloon counterpulsation. The role of catheter size and duration of support in a multivariate analysis of risk.

The aim of this study was to assess the risk of intra-aortic balloon counterpulsation and to identify clinical and procedural variables that would predict complications. We analysed 381 consecutive patients who were treated between 1977 and 1995 at our catheterization laboratory and/or medical intensive care unit. The complications considered relevant were limb ischaemia requiring catheter removal, vascular injury, bleeding requiring transfusion, embolic events, and infection. In eight patients the balloon could not be inserted. The rate of complications for the remaining 373 patients was 12.9%. Between 1977 and 1980, surgical insertion was performed using a 12 French catheter with a complication rate of 30.4% (seven of 23 patients). Percutaneous implantation, performed after 1981, had an overall complication rate of 11.7% (41 of 350 patients). 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). Multivariate logistic regression analysis identified duration of counterpulsation > 48 h (odds ratio 3.6), catheter size (odds ratio 3.4 for 12 French catheters), peripheral vascular disease (odds ratio 2.7), and shock (odds ratio 2.0) as independent risk factors for counterpulsation-associated complications. When considering 9.5 French catheters only (167 patients, all after 1992), the sole remaining independent risk factor was duration of counterpulsation > 48 h (odds ratio 3.8). Those patients with 9.5 French catheters in whom counterpulsation did not exceed 48 h had a low complication rate of 3.9%. The rate of percutaneous intra-aortic balloon counterpulsation complications was thus significantly reduced by employing thinner catheters. It was at an acceptable level for 9.5 French catheters, where a long duration of counterpulsation emerged as the most significant factor associated with complications. Whether using even thinner catheters in combination with a sheathless implantation technique further minimizes the risk of counterpulsation remains to be seen.

Prospective evaluation of complications associated with percutaneous intraaortic balloon counterpulsation

In summary, current, prospective experience with 691 consecutive patients revealed that female gender, peripheral vascular disease, cardiac index, and diabetes were the only independent predictors of risk after percutaneous IAB insertion. Neither sheathless insertion nor smaller IAB catheter size was associated with a lower complication rate. There may be a threshold of catheter size associated with a dramatic reduction in complications. If that exists, it has not yet been reached.

Atrial Septal Hematoma Immediately after Cardiac Surgery

Atrial Septal Hematoma Immediately after Cardiac Surgery

High-risk coronary angioplasty with elective intra-aortic balloon pump support

Percutancous transluminal coronary angioplasty was attempted with elective percutaneous intra-aortic balloon pump support in 21 patients (mean age 60 years, range 40–82; 18 males) with unstable angina ( n = 2), multivessel coronary disease requiring multivessel angioplasty ( n = 2), severe left ventricular dysfunction (ejection fraction 10–30%; n = 16) or ventricular fibrillation at diagnostic angiography ( n = 1). Fourteen patients had 3-vessel disease (1 with vein grafts also diseased), 6 had 2-vessel disease and 1 had isolated left anterior descending disease. Twenty-five procedures were performed (one in 18 patients, two in 2 patients and three in one patient) on 42 lesions in 34 vessels/grafts. There was no angioplasty-related death. Successful dilatation was achieved in 38 42 lesions (90%) in 21 25 procedures (84%) without major complication. Three procedures were complicated: one by major coronary dissection without sequelae, one by haemodynamic deterioration due to distal occlusion and one by an unstable residual stenosis in the attempted vessel necessitating urgent bypass surgery. The only complication related to the intra-aortic balloon pump was local haematoma in 2 patiens. In conclusion, elective intra-aortic balloon pump support may be safely used to stabilise high-risk patients undergoing coronary angioplasty, leading to a satisfactory primary success rate.

Sheathless insertion of the percutaneous intraaortic balloon pump: An alternate method

A technique is described that allows insertion of a standard percutaneous intraaortic balloon without use of the larger 12F sheath. Standard 9.5-cm. Percor balloons were inserted in a series of patients without using the provided sheath. Elimination of the sheath reduced the potential vascular complications related to the extra bulk placed in the femoral artery by the sheath. No serious complications were noted in more than 25 patients.

Aortoiliac Dissection After Percutaneous Insertion of an Intra-aortic Balloon Pump

Aortic or aortoiliac dissection may complicate percutaneous intra-aortic balloon pump insertion in various ways. Thrombosis can escape clinical recognition if no major obstruction develops. Death due to perforation after dissection is not uncommon. In this case study, aortoiliac dissection led to bilateral iliac artery stenosis, an unusual complication of percutaneous femoral cannulation for insertion of a balloon pump.

Complications of Percutaneous Intra-aortic Balloon Pump Use in Patients With Peripheral Vascular Disease

Percutaneous intra-aortic balloon pump use may carry an increased risk for patients with peripheral vascular disease. To determine the incidence and types of associated complications, the medical records of 144 patients who underwent a total of 153 percutaneous intra-aortic balloon pump insertions were reviewed. Patients were divided into two groups. Group 1 was composed of 20 patients with a history of peripheral vascular disease. Group 2 was composed of 124 patients without such history; they underwent a total of 133 insertions. Nineteen major complications (12%) occurred, 12 in group 1 (60% of 20 insertions) and seven in group 2 (5% of 133 insertions). Major complications were further classified by their nature: embolic, occlusive, and technical. All three types of complications occurred more frequently in group 1. Embolic complications occurred more frequently in patients with aneurysms and proved the most lethal, with two of six deaths in group 1 resulting from this complication.

A new technique for sheathless percutaneous intraaortic balloon catheter insertion

Intraaortic balloon counterpulsation is helpful for controlling myocardial ischemia and providing hemodynamic support, but its applicability is limited by lower extremity ischemic complications in a significant percentage of patients. We developed a new sheathless technique for percutaneous intraaortic balloon catheter insertion which reduces the effective catheter diameter. A pilot study using this new technique resulted in a 10% rate of limb ischemia, without compromise of balloon function. We conclude that this technique may be useful in reducing the incidence of limb ischemia associated with intraaortic balloon counterpulsation.

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.