Intra-aortic Balloon Pump Placement Research Articles

Early and mid-term outcomes of minimally invasive mitral valve surgery in high operative risk patients at University Medical Center, Ho Chi Minh City

Introduction: Minimally invasive mitral valve surgery (MIMVS) has seen significant advancement in the past decades, offering numerous benefits to patients. However, there remain cohorts of patients with mitral valve pathologies, deemed at higher surgical risk, who may face rejection for MIMVS due to concerns regarding potential postoperative complications associated with this approach. Objective: To assess early and midterm outcomes of MIMVS in higher-operative-risk patients at the University Medical Center of Ho Chi Minh City. Methods: A retrospective descriptive study of the patients meeting our high operative risk criteria, who underwent mitral valve surgery at the University Medical Center of Ho Chi Minh City from January 2017 to March 2023. Results: A total of 68 eligible cases were included in our study. The male-to-female ratio was 0.6:1. Among these cases, 21 patients underwent valve repair and 47 others underwent mitral valve replacement. 30.9% of cases presented with NYHA class III or above heart failure. The mean cardiopulmonary circulation time and aortic cross-clamp time were 157.4 ± 38.8 minutes and 102.7 ± 26.3 minutes, respectively. Three cases experienced minimally invasive surgery related complications, including one case of limb ischemia requiring fasciotomy, one case of femoral wound seroma, and one case of postoperative wound infection necessitating debridement. No instances of conversion to sternotomy or in-hospital mortality were observed. The mean ICU stay and postoperative length of stay at ward were 4.6 ± 3.5 days and 10.8 ± 5.9 days, respectively. Patients showed rapid recovery during the postoperative period. During ICU care, one patient suffered a non-disabling cerebrovascular accident, one case required continuous renal replacement therapy, three cases necessitated intra-aortic balloon pump placement, and three cases required reoperation due to hemorrhagic pleural effusion. During follow-up period, three patients died within 6 months, and another patient died after their surgery one year. Other patients had favorable outcomes at the time of discharge and at subsequent follow-up. Conclusion: Minimally invasive mitral valve surgeries highlight the feasibility and safety of minimally mitral valve surgery in higher-operative-risk patients.

Steady Flow Left Ventricle Unloading Is Superior to Pulsatile Pressure Augmentation Venting During Venoarterial Extracorporeal Membrane Oxygenation Support.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) shunts venous blood to the systemic arterial circulation to provide end-organ perfusion while increasing afterload that may impede left ventricle (LV) ejection and impair cardiac recovery. To maintain flow across the aortic valve and reduce risk of lethal clot formation, secondary mechanical circulatory support (MCS) devices are increasingly used despite limited understanding of their effects on cardiac function. This study sought to quantify the effects of VA-ECMO and combined with either intraaortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) on LV physiologic state and perfusion metrics in a porcine model of acute cardiogenic shock. Shock was induced through serial left anterior descending artery microbead embolization followed by initiation of VA-ECMO support and then placement of either IABP or pVAD. Hemodynamic measurements, LV pressure-volume loops, and carotid artery blood flow were evaluated before and after institution of combined MCS. The IABP decreased LV end-diastolic pressure by a peak of 15% while slightly increasing LV stroke work compared with decreases of more than 60% and 50% with the pVAD, respectively. The pVAD also demonstrated increased coronary perfusion and systemic pressure gradients in comparison to the IABP. Combined support with VA-ECMO and pVAD improves cardiovascular state in comparison to IABP.

491 Clinical and Radiographic Features of Mesenteric Ischemia after Intra-Aortic Balloon Pump Placement

OBJECTIVES/GOALS: Intra-aortic balloon pumps are commonly used as circulatory support in patients with critically reduced cardiac function. The goal of this study is to estimate the incidence of mesenteric ischemia as an understudied vascular complication and to describe the clinical and radiographic characteristics of patients experiencing this complication. METHODS/STUDY POPULATION: We will be conducting a retrospective analysis of the electronic medical records of all patients who underwent intra-aortic balloon pump (IABP) placement between October 2020 and April 2023 at our academic medical center to identify the incidence of mesenteric ischemia. We will describe the clinical course of these patients and characterize them based on demographic features and risk factors for vascular complications including medical comorbidities. Finally, we will assess available chest x-ray and thoracoabdominal CT imaging for adequacy of balloon tip positioning, concordance between balloon size and aortic dimensions, and compromise of any visceral arteries in patients who experienced mesenteric ischemia vs. those who did not. RESULTS/ANTICIPATED RESULTS: We anticipate approximately 150 patients to have recieved IABPs over this period with at least 4 known cases of mesenteric ischemia. We will describe the clinical presentation of these cases and their often fatal outcomes. We expect several known risk factors will be present in these patients, including history of peripheral vascular disease, diabetes, or smoking history. On chest x-ray, we predict balloon tip positioning to be suboptimal (defined as >5cm below the aortic arch) in many patients, both those with mesenteric ischemia and those without, but a greater discordance on CT imaging between balloon size and aortic dimensions with greater evidence of visceral compromise in patients with mesenteric ischemia compared to those without. DISCUSSION/SIGNIFICANCE: Mesenteric ischemia is a serious and poorly studied complication of intra-aortic balloon pumps. Understanding the hospital course, clinical characteristics, and radiographic features present in these patients may guide clinicians in the early recognition and management of this potentially fatal complication.

Abstract 13454: Safe Large Bore Access via the Third Part of the Axillary Artery for Mechanical Circulatory Support Implantation

For patients in cardiogenic shock, percutaneous mechanical circulatory support devices (MCSD) have emerged as critical tool to improve hemodynamics and optimize end-organ perfusion; successfully bridging patients to recovery, decision or transplantation. The most commonly utilized MCSD is the femoral intra-aortic balloon pump (IABP). However, femoral access hampers the patient's mobility, quality of life, and capacity to participate in rehabilitation. The advent of the axillary artery approach has served to circumvent limitations associated with the femoral artery approach. However, optimum anatomical placement of IABP within the axillary artery (axIABP) is a topic of debate considering its proximity to the brachial plexus. Here, we report our experince with percutaneous access of the third poriton of the axillary artery which showed promising results with minimal device related complications or adverse events. Methods/Results: Between 2017-2023, a total of 89 patients in cardiogenic shock underwent percutaneous axIABP placement at the Mayo Clinic, MN. All demographic, clinical, and periprocedural data were obtained from hospital chart review and recorded in a database under IRB approval. Indications for axIABP support was determined by multidisciplinary assessment. Complications encountered in the cohort included infection at site 6.7% (n=6), device malfunction [rupture, fracture, leak] 8.98%(n=8), and balloon migration 5.61% (n=5). One patient developed local erythema, 4 (4.49%) patients developed significant vascular complications, including access site bleeding in two patients 2.24%, arterial thrombosis in three patients 3.37%, and self-limited intracranial bleeding in one patient 1.12%. Of note, no nerve injury or damage was observed in the entire patient cohort. Conclusion: Our study highlights the feasibility of percutaneous axIABP in the third portion of the axillary artery, while assessing safety profile and ease of removal. Notably in our review, we did not encounter any brachial nerve damage. Ultrasound was pivotal in identifying and avoiding nerves and nerve bundles during initial access. In conclusion, this approach of axIABP insertion is feasible and can be leveraged for delivery of future innovation in MCSD

Abstract 15299: Cardiogenic Shock and Flash Pulmonary Edema in an Uncommon Nonischemic Nonmyxomatous Spontaneous Rupture of Anterolateral Mitral Valve Papillary Muscle

Introduction: Mitral valve papillary muscle rupture is a rare condition that presents a cardiac emergency requiring rapid identification and treatment. Here we present a case of flash pulmonary edema and cardiogenic shock from severe mitral regurgitation (MR) secondary to spontaneous rupture of the anterolateral papillary muscle. Case Presentation: A 48-year-old female with hypertension presented to the ED with acute shortness of breath. In the ED, she was tachycardiac, hypertensive, tachypnic and saturating 75% on room air. On physical exam a 3/6 systolic murmur was present at the apex. ECG had no signs of ischemia. TTE showed severe MR with a fail anterior mitral leaflet. The patient was intubated and taken emergently to the cath lab for intra-aortic balloon pump placement, TEE (Figure 1A) and coronary angiogram, which was normal (Figure 1B, 1C). She was taken to the OR for successful mitral valve replacement surgery. Discussion: The rapid clinical decline and emergent management of patients who develop cardiogenic shock with pulmonary edema from acute non-ischemic papillary muscle rupture presents a significant challenge for clinicians. The cause of papillary muscle rupture most often occurs due an ischemic event, but can occur spontaneously as in this case. Rapid identification of the etiology of the clinical symptoms is of upmost importance to increase chances of survival. On review, 11 cases have been published between 2000-2015 discussing nonischemic nonmyxomatous spontaneous papillary muscle rupture of which the majority had a posterior muscle rupture. In our case, the 48-year old patient only had mild chordal calcification and essential hypertension and presented with nonischemic nonmyxomatous rupture of the anterolateral muscle. With prompt identification and urgent multidisciplinary team intervention, the patient was eventually discharged after replacement and is doing well at 6 months follow-up.

Abstract 15948: Highly Suspicious Yet Diagnostically Unrevealing Left Ventricular Free-Wall Rupture Following STEMI

Introduction: Left ventricular wall rupture is a rare but lethal complication following a ST elevation myocardial infarction (STEMI). We present a case of left ventricular free-wall rupture not identified on echocardiography and CT angiography (CTA) despite high suspicion who underwent emergent lifesaving mediastinal exploration and repair. Case: A 52-year-old male with past medical history of hypertension presented with typical chest pain. He was found to have STEMI with 100% left anterior descending (LAD) artery occlusion and underwent percutaneous coronary intervention to mid LAD. Post procedure, he developed atrial fibrillation with rapid ventricular rate, pericarditis, increasing pericardial effusion (Figure 1), and cardiogenic shock. He underwent intra-aortic balloon pump placement with no improvement in hemodynamics and subsequently an Impella 5.5 was placed. On post MI Day 3, he underwent pericardial window in the setting of shock and increasing pericardial effusion. Intraoperative TEE showed signs of tamponade physiology (Figure 2). Repeat echocardiograms and CTA was unrevealing of a rupture. Post MI day 6, he had increasing output from the drains and increasing pericardial effusion with complete right ventricular collapse on bedside echocardiogram. Emergent mediastinal exploration revealed left ventricular (LV) free-wall rupture which was repaired with a bovine patch. Hemodynamics improved and goal directed medical therapy was started. Discussion: Free wall rupture is a rare complication post MI and is reported in only 0.01% of STEMI. It usually occurs within 1 week, majority occurring within 24 h of MI. Small LV wall rupture can be challenging to diagnose on cardiac imaging. This case emphasizes the importance of having a high index of suspicion for diagnosing free wall rupture in patients presenting with hemodynamically unstable pericardial effusion post STEMI. Prompt pericardiocentesis and surgical intervention lead to a good outcome.

Mechanical ventilation in acute myocardial infarction: Outcomes from a prospective audit at a cardiovascular hospital in Pakistan.

This clinical audit aims to evaluate the clinical data regarding the management and outcomes of acute myocardial infarction (AMI) patients requiring mechanical ventilator (MV) support, along with identifying factors associated with prolonged MV support and 180-day mortality. In this study, we audited clinical data regarding management, in-hospital and short-term outcomes of adult patients with AMI required MV support. Patients with prolonged MV duration (>24h) and/or 180-day mortality were compared with their counterparts, and associated factors were identified. The binary logistic and Cox regression analyses were performed to determine the predictors of prolonged MV duration and 180-day mortality. In a sample of 312 patients, 72.8% were male, and the mean age was 60.3±11.5 years. The median MV duration was 24 [24-48] hours, with 48.7% prolonged MV duration. The admission albumin level was found to be the independent predictor of prolonged MV duration with an adjusted OR of 0.42 [0.22-0.82]. Overall 7.4% were re-intubated, 6.7% needed renal replacement therapy, 17.6% required intra-aortic balloon pump (IABP) placement, and 16.7% required temporary pacemaker placement. The survival rate was 80.4% at the time of hospital discharge, 74.7% at 30-day, 71.2% at 90-day, and 68.6% at 180-day follow-up. Age, prolonged MV duration, and ejection fraction were found to be the independent predictors of cumulative 180-day mortality with adjusted HR of 1.04 [1.02-1.07], 1.02 [1.01-1.03], and 0.95 [0.92-0.98], respectively. Prolonged ventilator duration has significant prognostic implications; hence, tailored early recognition of high-risk patients needing more aggressive care can improve the outcomes.

Outcomes of ST-Segment Elevation Myocardial Infarction in a Cohort of Cardiogenic Shock Patients Undergoing Primary Percutaneous Coronary Intervention

Objectives: The objective of this study was to investigate the immediate and short-term mortality rates among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) who underwent primary percutaneous coronary intervention (PCI). Methodology: This observational study was conducted at a tertiary care cardiac center in Pakistan. We included consecutive patients diagnosed with STEMI complicated by CS who underwent primary PCI. We analyzed the clinical characteristics, management strategies, and in-hospital as well as short-term follow-up outcomes of the patients. Results: A total of 200 patients were included in the study, of which 74.5% (149) were male, and the mean age was 57.96 ± 12.52 years. The majority of patients were classified as Killip class III (64.0%, 128), while the remaining were classified as Killip class IV. On arrival, arrhythmias were observed in 37.5% (75) of the patients, 27.5% (55) were in cardiac arrest and 84.5% (169) required intubation. Intra-aortic balloon pump (IABP) placement was performed in 31.5% (63) of the patients, and temporary pacemakers (TPM) were placed in 18.5% (37). The in-hospital mortality rate was found to be 10.5% (21). During a mean follow-up period of 177 days (141.5-212.5), a cumulative major adverse cardiovascular event (MACE) was observed in 48% (96) of the patients, with an all-cause mortality rate of 28% (56). Additionally, re-infarction occurred in 7.5% (15) of the patients, and re-hospitalization due to heart failure was noted in 23.5% (47) of the patients. Conclusion: Our study revealed an in-hospital mortality rate of 10.5% following primary PCI in patients with CS. At approximately six months after the acute event, nearly half of the patients experienced MACE, with a notable mortality rate of 28%. These findings highlight the critical nature of CS and emphasize the need for further research and interventions to improve outcomes in this high-risk patient population.

Thoracic Aortic Injuries Following Intra-Aortic Balloon Pump Placement: A Retrospective Case Series.

Retrospective, single-institution study through chart review of five patients with known thoracic aortic injuries following IABP placement awaiting heart transplant. Tertiary care academic teaching hospital with all patients requiring cardiac ICU admission. All five patients were diagnosed with advanced heart failure awaiting heart transplantation. Each patient had an IABP placed while awaiting transplant. Five patients (4.6%) out of a total of 107 supported with IABP awaiting heart transplantation were identified with thoracic aortic injury. Three underwent transplantation and subsequently received thoracic endovascular aortic repair, and they are doing well with a mean follow-up of 6 months. One patient died acutely and the other did not require intervention. IABP-related aortic injuries may be more common in patients awaiting transplantation and that endovascular therapy is a suitable treatment modality with no immediate impact on transplantation outcomes. Pooled data from multiple centers may help identify patients risk profile to potentially design an algorithm that can more quickly identify these injuries.

D-39 | Inpatient Outcomes of Mitral Valve Transcatheter Edge-to-Edge Repair (TEER) in Patients With Acute Decompensated Heart Failure

TEER is a favorable alternative to surgery in patients with heart failure (HF) and mitral regurgitation (MR), but its effect in acute decompensated heart failure (ADHF) is not well studied. We aim to study the short-term outcomes of TEER in these patients using the largest US inpatient database. We queried the 2016-2019 NIS database using ICD-10 codes to identify all adult patients with MR and ADHF. Outcomes of patients who underwent TEER during index hospitalization were compared to those who did not. Multivariate logistic regression was used to compare rates of cardiogenic shock, mechanical ventilation, use of mechanical circulatory support (MCS), cardiac transplant, acute kidney injury (AKI) and need of dialysis; linear regression was used to compare length of stay (LOS). Of 1,854,806 patients with MR and ADHF, 24,905 (1.36%) underwent TEER. Overall mortality was 3.39% and was significantly lower in TEER recipients [aOR 0.39 (0.30-0.49), p<0.01]. LOS was significantly shorter in the TEER group (4 vs 5.9 days). TEER group had lower rates of mechanical ventilation [aOR 0.81 (0.70-0.94), p=0.01] and AKI [aOR 0.43 (0.39-0.47), p<0.01], although rates of AKI requiring dialysis were comparable. TEER group had significantly higher rates of cardiogenic shock. Rates of MCS were comparable except intraaortic balloon pump placement, which was more frequent in the TEER group. TEER in ADHF is associated with lower rates of inpatient mortality and mechanical ventilation, and shorter LOS. Prospective trials are needed to establish TEER as a feasible intervention in ADHF.

2013. Bloodstream Infections in Advanced Heart Failure Patients Requiring Prolonged Use of Axillary Intra-Aortic Balloon Pumps - A Single Center Study

Abstract Background Bloodstream infections (BSI) impact outcomes in critically ill patients. Institutions and quality and performance improvement efforts to minimize catheter associated infections are valued to optimize outcomes. While intra-aortic balloon pumps (IABP) implanted through the axillary route have been recently used in cardiogenic shock patients for prolonged support, the incidence and associated significance of BSI remains unknown in this cohort. The aim of this study was to assess the incidence of BSI in patients with axillary-placed IABP and evaluate its impact on patient outcomes. Methods We retrospectively reviewed 141 patients that underwent axillary IABP placement from May 2016 through August 2020. The primary endpoint was the incidence of BSI during axillary IABP, reported as the proportion of patients who developed a BSI and BSI per 1000-device days. Results BSI occurred in 13% of patients and accounted for 4.3 infections per 1000-device days. Prior femoral device use and longer duration of axillary IABP support occurred more frequently in the BSI cohort. Presence of traditional BSI risk factors including central line days, use of parenteral nutrition, and prior positive cultures did not differ between those who developed BSI and those who did not. The rate of end-outcome attainment (transplant, LVAD, recovery) was not statistically different in those that developed BSI vs not (72% vs 88% p=0.08). A total of 41% of BSI were caused by Staphylococcus epidermidis. Use of peri-procedural antimicrobials was associated with lower risk of BSI development (24% vs 8%; p=0.01) Conclusion Patients in cardiogenic shock requiring use of life-saving temporary mechanical support pose a challenge to maintain free of BSI during prolonged support with an indwelling catheter that allows for ambulation and movement. Mitigation of modifiable BSI risk factors, such as the use of peri-procedural antimicrobial prophylaxis, accompanied by a low threshold for screening and treatment are reasonable strategies to improve patient outcomes. Future research is needed to further evaluate BSI risk in this patient population and its subsequent impact on patient outcomes. Disclosures All Authors: No reported disclosures.

Intra-aortic Balloon Pump Securement.

Intra-aortic Balloon Pump Securement.

Abstract 14682: Gender Disparities in Hypertrophic Cardiomyopathy After Septal Myectomy - Insights From the National Inpatient Sample 2011-2019

Introduction: Data suggests that women with hypertrophic cardiomyopathy (HCM) have worse clinical outcomes than men. However, data from large multi-center studies on gender differences in patients who undergo septal myectomy (SM) is scarce. Methods: The National Inpatient Database was queried from 2011- 2019 for relevant ICD-9 and -10 diagnostic and procedural codes. We compared baseline characteristics and in-hospital outcomes of patients with HCM who underwent SM stratified according to male vs. female gender. A p-value &lt;0.001 was considered statistically significant. Results: We identified 10,805 patients with HCM who underwent SM, of which 55.4% were female. Women were significantly older (60.9 vs. 56.3 years), had more obesity (31% vs. 26.8%), heart failure (44.6% vs. 40%), chronic obstructive pulmonary disease (12.2% vs. 9.2%) and pulmonary hypertension (16.2% vs. 11.5%) (p&lt;0.001 for all) compared to men. Men had more hypertension (75.4% vs. 69.7%), tobacco use (41.5% vs. 34%), alcohol use (3.5% vs. 1.4%), hyperlipidemia (59.3% vs. 55.6%), obstructive sleep apnea (25.9% vs. 15%), coronary artery disease 41% vs. 32%), chronic kidney disease (12.6% vs. 8.7%), atrial fibrillation (46% vs. 40.9%), and atrial flutter (8.5% vs. 4.7%) (p&lt;0.001 for all) compared to women. In-hospital outcomes demonstrate women had higher all-cause mortality (3.3% vs. 1.6%, OR: 2.4 [1.5-4]) and more frequently required intra-aortic balloon pump placement (OR: 6.9 [2.7-19]) compared to men. Men had more intraoperative cardiac complications (OR: 1.4 [1.1-1.6]), pneumothorax (OR: 1.7 [1.25-2.5]), and pericardial complications (OR: 10 [3-33]) (p&lt;0.001 for all) compared to women. Conclusions: In patients with HCM who underwent SM, women had higher all-cause mortality despite having less comorbidities than men. These highlights potential gender differences in outcomes in patients referred for SM. Whether biases exist in referral patterns needs to be further elucidated.

Intra-Aortic Balloon Pump Placement in the Axillary Artery: Where are We?

Intra-Aortic Balloon Pump Placement in the Axillary Artery: Where are We?

The effect of anesthesia management on mortality and morbidity in patients who underwent transcatheter aortic valve implantation

Objectives: We aimed at investigating the effects of two different anesthesia techniques in our patients who underwent transcatheter aortic valve implantation (TAVI). Material and methods: The effects of two different anesthetic methods were retrospectively evaluated in 100 patients who underwent TAVI between January 2010 and October 2020. Patients were divided into a general anesthesia (GA) group and a sedation-local anesthesia (S-LA) group according to the anesthetic methods used. Results: Of 100 patients who underwent transcatheter aortic valve implantation, 20 (20%) received GA, and 80 (80%) received S-LA. The mean ages of the patient groups undergoing GA and S-LA were 76.20±7.22 and 75±8.44 years, respectively. The duration of the procedure and anesthesia was significantly longer in the GA patient group than in the S-LA patient group. With the exception of the logistic European Society of Cardiac Operative Risk Assessment, the demographic and preoperative data of the two groups were similar. The most common comorbidity in both groups was hypertension. When comparing complications between groups, the incidence of intraoperative hemodynamic instability, ephedrine use, inotropic drug use, intra-aortic balloon pump placement, postoperative infection and cardiac tamponade was significantly higher in the GA group. The length of intensive care and hospital stay was similar between the groups, but the 30-day and 3-month mortality rates were significantly higher in the GA group than in the S-LA group. Conclusion: S-LA provided more stable hemodynamics, shorter operative and anesthetic times, fewer intraoperative and postoperative complications, and reduced mortality. S-LA application during the TAVI procedure is a more reliable alternative to GA.

The impact of initiating quality of care improvement protocols on intensive care unit length of stay in patients undergoing coronary artery bypass grafting: An insight from a nascent program

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Prolonged intensive care unit (ICU) length of stay (LOS) post coronary artery bypass grafting (CABG) constitutes a major challenge for both patients and cardiac surgery teams. While Identifying predictors of prolonged patients’ stay in the ICU can further optimise ICU resource utilization, the role of initiating QOC improvement protocols aimed to reduce ICU LOS for these patients has been widely advocated. Therefore, we aim in our study to evaluate the overtime impact of initiating QOC improvement protocols on ICU LOS and present patient characteristics predicting prolonged ICU stay in patients undergoing CABG in a nascent program. Methods We included consecutive patients (n=976) undergoing CABG at a newly established tertiary centre between June 2015 and September 2021. Data on baseline characteristics and presentation, in addition to intraoperative details and outcomes, were collected retrospectively. Patients with prolonged (≥48h) and short (&amp;lt;48h) ICU LOS were compared by appropriate testing methods. Predictors of prolonged ICU LOS were determined by multivariable logistic regression. Continuous development of ongoing protocols to improve QOC was taken, including but not limited to; enhancing diabetic control, coronary perfusion and renal function. Trends in prolonged ICU LOS were determined using Joinpoint Software of the National Cancer Institute to calculate the average annual percentage change (AAPC). Results QOC improvement protocols initiation was associated with a 33.7% reduction in the proportion of patients having prolonged ICU LOS post- CABG between 2015 to 2021 ( AAPC: -5.3 , 95%CI [-7.7, -2.9], p&amp;lt;0.001) . Overall, 56.4% (551/976) of patients had prolonged ICU LOS. In comparison to individuals with short ICU LOS, patients who overstayed in the ICU were significantly older, females, diabetic, with higher burden of peripheral vascular disease (Table). On presentation, the prolonged LOS group was featured by worse NYHA class, higher rates of acute myocardial infarction (MI), lower ejection fraction (EF), higher serum creatinine and more frequently required preoperative intra-aortic balloon pump (IABP) insertion (Table). Aortic cross-clamp time and type of surgery were comparable between groups. Unfavorable outcomes were noticed in the prolonged ICU LOS group regarding postoperative adverse events and mortality. On multivariable logistic regression, age, female gender, NYHA class ≥II, MI on presentation, preoperative creatinine level, preoperative EF and preoperative IABP placement were independent predictors for prolonged ICU LOS (Figure). Conclusion In this study, initiation of QOC improvement protocols was associated with a significant reduction in prolonged ICU LOS. While multiple risk factors prolonging ICU LOS were identified, future studies are required to further incorporate these risk factors into ongoing protocols aimed to optimise resources utilisation and enhance the QOC in CABG patients.

Ruptúra voľnej steny myokardu ako komplikácia STEMI

Myocardial free wall rupture is a rare, but serious complication of acute myocardial infarction with high mortality. We present a case of a 64-year-old patient with this devastating complication of an anterior ST segment elevation myocardial infarction (STEMI) with a prolonged time delay. Cardiac surgery was not performed due to prohibitive surgical risk and predicted poor prognosis. We describe our successful therapeutic intervention consisting of immediate pericardial drainage, vasoactive and inotropic support, intraaortic balloon pump placement and continuous veno-venous hemodialysis. This combined therapy led to patient stabilization and after incremental clinical improvement the patient was able to return to a normal life. After several months a long-term mechanical circulatory support was implanted as a bridge to heart transplant.

Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock

Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock

Contemporary Single-Center Experience with Axillary Intra-Aortic Balloon Pumps

<h3>Purpose</h3> Intra-aortic balloon pumps (IABP) are increasingly being utilized to augment hemodynamic support in patients awaiting heart transplantation. In this subset of patients, the use of axillary IABP has the benefits of allowing increased mobility and decreased risk of infection when compared to the femoral approach for IABP. To further gain insight into the risks and benefits of this approach, we performed a retrospective review of our center's experience with axillary IABP. <h3>Methods</h3> We conducted a retrospective review of adult patients undergoing axillary IABP placement from July 2017 to April 2021. Variables collected included general patients' characteristics such as gender, age and comorbidities, indication for axillary IABP placement, hemodynamic parameters before and after IABP, days on axillary IABP, days from initial axillary IABP to transplant, postoperative and device complications. <h3>Results</h3> A total of 42 adults underwent open axillary IABP placement during the study period. Mean age was 52 years and most of the patients were male. The most common etiology was non-ischemic with an indication of bridge to transplantation (BTT) (<b>Table</b>). Successful orthotopic heart transplantation was performed in 40 of these patients. Mean duration of axillary IABP support was 19 days and mean duration from initial axillary IABP insertion to transplant was 27 days. Cardiac output and cardiac index significantly increased after IABP placement (p<0.001). Ten patients required one balloon exchange and two required two exchanges. Device malfunction was the most common IABP complication and acute kidney injury was the most common patient complication. There were no mortalities related to IABP placement. <h3>Conclusion</h3> Axillary intra-aortic balloon pump use has risen over the past years. The most common indication for axillary IABP at our institution was BTT with a success rate of 97.5%. The most common balloon complication was malfunction requiring an exchange, and the most common patient complication was acute kidney injury.

Intra-Aortic Balloon Placement without Inotropes: A Shift in Practice for Higher Urgency Status for Patients Awaiting Heart Transplant?

<h3>Purpose</h3> The donor heart allocation policy was changed in October 2018, allowing priority for waitlist candidates with intra-aortic balloon pump (IABP) support over those with inotropic support. The use of IABP has increased several-fold since the donor heart policy was put into effect in October 2018. We assessed the UNOS registry to determine if this increase was due to a shift in practice or due to increased patient instability. <h3>Methods</h3> We reviewed 128 patients in UNOS on IABP awaiting HTx April 1, 2017 - April 1, 2018, and compared them to the 446 patients in UNOS on IABP awaiting HTx November 1, 2018 - November 1, 2019. The patients were further divided into groups based on concomitant use of inotropic support and compared pre- and post-allocation change. 30-day and 1-year survival post-HTx were assessed. <h3>Results</h3> In the post-policy era period of 2018, the placement of IABP without inotropes increased by 3.4-fold compared to 1 year prior to the policy change. For all patients with IABP placement, time from listing to transplant was significantly shorter after the policy change. There was no difference in 30-day and 1-year survival (Table 1). <h3>Conclusion</h3> There appears to be a shift in practice where IABP support is used without inotropic support after the donor heart allocation policy change. This suggests that physicians are using IABP in place of intravenous inotropes to advocate for their patients for a higher urgency status and donor availability. This should be taken into account in the revision of future donor heart allocation policies.