Trans Thoracic Intraaortic Balloon Pump Support

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DOI:10.1016/S0003-4975(10)62350-81987;44:26-30Ann Thorac Surg

Horace MacVaugh, IIIWilliam McGeehin, Feroz Sheikh, James S. Donahoo, Michael J. Lechman and

Transthoracic Intraaortic Balloon Pump Support: Experience in 39 Patients

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Surgeons. Print ISSN: 0003-4975; eISSN: 1552-6259.the Southern Thoracic Surgical Association. Copyright 1987 by The Society of Thoracic

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Transthoracic Intraaortic BalloonPump Support: Experience in 39 PatientsWilliam McGeehin, M.D., Feroz Sheikh, M.D., F.R.C.S.(G),James S. Donahoo, M.D., Michael J. Lechman, M.D.,and Horace MacVaugh, 111, M.D.

ABSTRACT From June, 1982, through July, 1985, 39(1.5%)of 2,570 patients undergoing open-heart proceduresrequired insertion of a transthoracic intraaortic balloonpump (IABP). In all of these patients, a percutaneous at-tempt failed or was contraindicated. There were 24 (62%)men and 15 (38%)women. The mean age was 64.9 years.Five patients (13%) ustained complications potentially re-lated to the transthoracic IABP. They included mediastinalinfection in 1 patient (2.5%),balloon rupture in 2 patients(5%), and cerebrovascular accidents in 4 patients (10%).The overall survival was 44%. Survival for the group ofpatients weaned from transthoracic IABP support was 17(81%)of 21. There were no deaths directly related to thetransthoracic IABP. The transthoracic IABP was removedunder local anesthesia without sternotomy in 19 (90%)ofthe patients weaned and with formal sternotomy in theremaining 2 (9%). n a select group of patients requiringintraaortic balloon counterpulsation, the use of the trans-thoracic IABP is a reasonable second choice for patients inwhom other methods of balloon support are not feasible.The benefit of the intraaortic balloon pump (IABP) incardiac surgical patients to help wean them from car-diopulmonary bypass (CPB) is well established [I , 21.Failure to wean from CPB and postoperative hemody-namic deterioration preselect a group of patients with apoor prognosis. Since its introduction in 1972, ballooncounterpulsation has proved to be lifesaving in manydesperate situations in the operating room. In patientswith severe aortoiliac disease, the standard femoralroute of insertion may not be possible. Failure to placethe balloon by the femoral or iliac route is a serious limi-tation to the effectiveness of this technique.

The incidence of failure to insert the IABP through thefemoral route is fairly high, ranging from 13 to 21 % [3,41. For this group of patients, transthoracic insertion ofthe balloon through the ascending aorta has been sug-

From the Department of Surgery and the Division of Thoracic and Car-diovascular Surgery, Lankenau Hospital, and the Division of Car-diothorcicic Surgery, Graduate Hospital, Jefferson Medical College ofThomas Jefferson University, Philadelphia, PA.Presented at the Thir tythird Annual Meeting of the Southern ThoracicSurgical Association, White Sulphur Springs, WV, Oct 30-Nov 1, 1986.Address reprin t requests to Dr. Donahoo, Department of Surgery, Lan-kenau Hospital, Lancaster Ave west of City Line, Philadelphia,PA 19151.

gested [5], considered [l] , r occasionally attempted [2,41. Most studies of this technique comprise single casereports [6, 71. In life-threatening situations, the ballooncatheter may be passed into the descending thoracicaorta through the iliac arteries [8], subclavian artery [9],axillary artery [lo], or abdominal aorta [lo]. This reportdeals with the use of the ascending aorta as a second-choice site for IABP insertion following failure of or con-traindication to femoral artery cannulation by a per-cutaneous or surgical technique.Material and M ethodsA retrospective review of all patients undergoing inser-tion of the transthoracic IABP from June, 1982, to July,1985, was performed. During the 43-month study pe-riod, 39 of 2,570 patients undergoing open-heart proce-dures required such assistance. Coronary artery bypassgrafting (CABG) was done in 24 of the 39 patients,CABG and valve replacement in 10, isolated valve re-placement in 4, and double valve replacement in 1.Twenty-four (62%) of the patients were men, and 15(38%) were women. The mean age was 64.9 years(range, 33 to 86 years). The transthoracic IABP was in-serted intraoperatively in 31 (79%)patients and postop-eratively in 8 (21%). The mean length of counterpulsa-tion support in survivors was 83 hours (range, 24 to 168hours). The mean length of support in patients weanedfrom the balloon who did not survive was 89.1 hours(range, 48 to 120 hours).TechniqueInsertion of the transthoracic IABP is carried out in theoperating room in most instances and occasionally in thesurgical intensive care unit (SKU). A partial occlusiveclamp is placed on the ascending aorta where an aor-totomy is made (Fig 1). A polytetrafluoroethylene(PTFE) 10-mm prosthesis is sutured to the site with 5-0polypropylene running suture. The partial occlusiveclamp is removed, and then a vascular clamp is placedon the prosthesis. The 60-cc SMEC (Schiff Medical Elec-tronics Company) balloon is used.

Before insertion, a gradual downward bend is made inthe distal end of the somewhat stiff catheter. This ma-neuver gives a curved contour to the balloon catheter.After it has been passed through the prosthetic conduit,the catheter can be guided directly over the aortic archand avoid arch vessel cannulation. The positioning ofthe balloon just distal to the left subclavian artery is ap-proximated by relating the total length of the balloon

26 Ann Thorac Surg 44:26-30, July1987

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27 McGeehin, Sheikh, Donahoo, et al: Transthoracic IABP Support

Fig 1 . The polytetrafluoroethylene (PTFE)10-mmprosthesis is sewnto the ascending aorta (Ao)and the balloon is inserted and positionedin the descending thoracic aorta. A heavy tie around the distal end ofthe graft over a sliding plastic sleeve on the balloon catheter provides ahemostatic closu re of t he graft.catheter to the length inserted. At closure, the graft liesover the heart with the distal portion exiting inferiorly tothe closed sternum. The end of the graft is enclosed inthe subcutaneous portion of the incision. The ballooncatheter alone exits at skin level (Fig 2).In the immediate postoperative period, heparin ordextran is not used. Vancomycin is administered for theentire course of balloon pump therapy. The left pleuralspace is not routinely opened for manual inspection ofballoon placement. A heavy tie around the distal end ofthe graft over the sleeve of the balloon catheter provideshemostatic fixation of the balloon within the graft.Removal of the transthoracic IABP is done in the SICUunder local anesthesia. The lower portion of the ster-notomy incision is opened. The securing tie is cut, andthe balloon is removed. A vascular clamp is applied tothe graft. The distal end of the graft is excised, and theremaining portion is oversewn and ligated. The graftstump retracts into the subcutaneous tissue. After copi-ous irrigation with dilute povidone-iodine solution, thesubcutaneous tissue and skin are closed (Fig 3).lndicationsThe indications for balloon counterpulsation included(1)failure to wean from CPB, (2) known advanced aor-toiliac occlusive disease, (3)previous abdominal aortic orfemoral artery operation, and (4) postoperative per-

cutaneous balloon dependence with ischemia of thelower extremity.ResultsTwenty-one patients (54%)were weaned from balloonsupport. In 19 (90%)of them, removal of the balloon wascarried out under local anesthesia in the SKU. Two pa-tients (9%) were returned to the operating room for re-peat sternotomy and excision of the PTFE prosthesis.The overall survival among the 39 patients was 44% (17139). Six of the 22 patients who died were never weanedfrom the balloon. There were no deaths related directlyto balloon placement or removal. Survivors were dis-charged at a mean of 19 days postoperatively (range, 9 to48 days).Five patients (13%)sustained a total of seven compli-cations including balloon rupture, graft infection, andcerebrovascular accidents. Rupture of the balloon(marked by the sudden appearance of blood in the bal-loon tubing) occurred in 2 patients and necessitated im-mediate removal of the balloon. In both patients, theballoon was removed quickly under local anesthesia, aspreviously described, without untoward effect.

Graft infection documented by positive cultures devel-oped in 1patient. The balloon was inserted in the oper-ating room at the time of CABG. When the patient be-came independent of balloon counterpulsation on thefourth postoperative day, the IABP was removed underlocal anesthesia. On the tenth postoperative day, thepatient became septic and purulent material drainedfrom the middle of the sternotomy incision. He was re-turned to the operating room where mediastinal de-bridement and excision of the PTFE graft were per-formed. The patient died of myocardial infarction andrenal failure on the nineteenth postoperative day.Four patients sustained strokes. In each instance, theneurological deficit was appreciated in the first 24 hourspostoperatively before the thoracic balloons were re-moved. Three of these patients died of multiple-organfailure. One patient recovered and was discharged witha left hemiparesis.CommentInsertion of a balloon catheter through the ascendingaorta has been used in children [ l l ] nd adults in whomthe femoral arteries are extensively diseased or do notallow a safe passage because of previous aortoiliac re-constructive procedures. Pappas [12] used this tech-nique to provide pulsatile CPB. Shirkey and colleagues[13] chose the transthoracic IABP to take advantage ofthe accessibility t gives to the aorta and to provide short-term IABP support to permit weaning from CPB. If thepatient required IABP support in the postoperative pe-riod, the balloon was transferred to the femoral artery.Macoviak and co-workers [14] used the transthoracic ap-proach in one-fourth of their intraoperative insertions toassist in weaning from CPB, chiefly because the surgeonpreferred this technique to the standard femoral route.Our indications for inserting the balloon in the ascend-

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28 The Annals of Thoracic Surgery Vo l 44 No 1 July 1987

Fig 2 . The PTFE prosthesis lies under th e stern um , and the ballooncatheter is brought ou t at the lower portion of the sternotomy inci-sion. (A-P = anteroposterior.)

ing aorta at operation are a failed percutaneous or opensurgical attempt and previous aortoiliac or femoral re-constructive procedures.

A variety of techniques for inserting the transthoracicIABP in the ascending aorta have been reported. Theycan be divided into two groups: techniques that use aprosthetic conduit from the aorta to subcutaneous tis-sues [ lo, 14-17] and techniques that use pledgeted orpursestring sutures to secure the balloon catheter in theascending aorta [7 , 12, 131.

The former group eliminates the need for repeat ster-notomy, and the balloon is removed in the intensive careunit without general anesthesia. Our technique of trans-thoracic balloon insertion with the prosthetic tube graftand removal in the SICU under local anesthesia withoutthe need for sternotomy is similar to the technique de-scribed by Bolooki [ lo] , Meldrum-Hanna and associates[15], Phillips and colleagues [18], and Macoviak and col-leagues [14]. The graftless technique of using pledgetedsutures to secure the balloon catheter in place as de-scribed by Shirkey and colleagues [13] and Bonchek andOlinger [7] has the disadvantage of requiring a ster-notomy for removal. Phillips and co-workers [18] re-ported that a patient had intermittent massive hemor-rhage when the balloon pumping chamber extrudedfrom the aorta after being placed with this technique.The use of a prosthesis also helps prevent frictional re-sistance at the time of balloon removal.

With the graftless technique, there is always the possi-bility that a thrombus on the balloon catheter or theballoon could be stripped off by the aortic wall as thecatheter is withdrawn [7]. Nuiiez and co-workers [17]described a technique of attaching a fabric graft to theaorta without applying a partial occlusion clamp by us-ing partial-thickness sutures in the wall of the aorta.They selected this technique because of lack of space inthe ascending aorta. With the partial occlusion clamp,we have always found enough room to apply the clampeven when the aorta is crowded with multiple saphe-nous vein grafts. Tchervenkov and Salerno [16] used theSeldinger technique for insertion of the balloon in theascending aorta and reported inadvertent cannulation ofsubclavian artery. We do not use this technique becausethe course of the guidewire cannot be predicted unlessfluoroscopy is used [ lo] .

A variety of complications caused by the IABP havebeen reported. Most important and most frequently en-countered complications are leg ischemia and arterial in-jury including aortic dissection and infection [l-41. Asdemonstrated by Isner and colleagues [19] in a postmor-tem study, most complications of the balloon appear toresult from insertion of the device and not as a conse-quence of its being in place. Because of the high rate ofcomplications, we desist when difficulty is encounteredwith the femoral route of balloon insertion and opt forthe transthoracic route as safer in these situations. Fa-vorable experience with this technique has given rise toour 1.5% rate of insertion among patients having anopen-heart procedure, a larger figure compared withthose from other institutions.

Transthoracic insertion of the IABP eliminates most

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29 McGeehin, Sheikh, Donahoo, et al: Transthoracic IABP Support

Fig 3 . The balloon is removed in the inten sive care unit under localanesthesia. The lower portion of the sternotomy incision is opened,and the balloon is dejlated and removed. The PTFE prosthesis is thenligated or oversewn , and the skin incision closed.problems associated with femoral insertion. There aremany reports of uncomplicated transthoracic insertion(6 , 7, 10, 13-15, 171. Complications resulting from hav-ing a transthoracic IABP in place include hemorrhage,embolism, and infection. In discussing complications ofIABP insertion, Pennington and colleagues [l] noted anincidence of zero percent when the transthoracic routewas used for balloon insertion compared with 15 and10 % for the percutaneous and femoral arteriotomy tech-niques, respectively. In the series of Macoviak and co-workers [141, the incidence of complications was sig-nificantly less (4%)when the balloon was inserted in theascending thoracic aorta rather than through the femoralor iliac route (31% ) .In our series, complications associated with the trans-thoracic IABP included graft infection, balloon rupture,and stroke. Graft infection in the ascending aorta is apotentially lethal complication. A short graft, systemicantibiotics, and use of saphenous vein instead of a pros-thetic graft are a few of the preventive measures recom-mended [lo]. McCabe and co-workers [4] reported ex-sanguination and death because of late infection in apatient with an IABP inserted by the transthoracic routethrough a Dacron graft. Once graft infection and medi-astinitis develop, graft removal may require CPB be-cause of friability of the aorta [14, 151. We have had one

instance of graft infection and mediastinitis. The graftwas removed successfully with mediastinal irrigationand debridement without CPB.Peripheral embolization of a thrombus associated withthe IABP or its graft is uncommon [l, 21. The risk ofcerebral embolization from a thrombus at the time ofballoon removal is a potential complication [7, 141. Forthis reason, Bonchek and Olinger [q nared the cerebralvessels during balloon removal, and Shirkey and col-leagues [13] kept the patient fully heparinized while thetransthoracic IABP was in place. Although 4 patients inour series had a stroke, it was not related to balloonremoval in any of them. The neurological deficit in eachpatient was recognized in the first 24 hours after opera-tion, and there was no evidence to implicate the trans-thoracic IABP. Each of these patients had multiple otherrisk factors. Peripheral embolization resulting in spinalcord ischemia and paraplegia [14], left coronary arteryocclusion [15], and bilateral renal artery occlusion [20]have been reported following removal of a transthoracicIABP.Balloon rupture and gas escape into the aorta is a rarecomplication [l]. We have had two such incidenceswhere the appearance of blood in the catheter was anindication of a communication between the inflatingchamber of the balloon and the aortic lumen. The bal-loon was promptly removed in each patient withoutcomplication.Aberrant cannulation of a cerebral vessel, left subcla-vian artery, or renal or superior mesenteric artery, espe-cially in children [lo], is a possible complication with thetransthoracic IABP. Ischemia of the left arm because ofaberrant cannulation of the subclavian artery by thetransthoracic IABP has been reported [15, 161. We havenot observed aberrant cannulation in our patients.Balloon pump insertion seems to have the greatestsuccess and the lowest rate of complicationsin patientswho need it least. Severe complications occur in desper-ately ill patients with cardiogenic shock and aortoiliacobstruction in whom the IABP is most difficult to insert.In urgent and desperate situations, there is always atendency to push the balloon to negotiate the difficultaortoiliac segment, and the increased risk of this maneu-ver is accepted because of the patient's grave condition.The transthoracic route of balloon insertion in theseselect groups of patients is a good second choice, whichavoids most of the complications associated with inser-tion of the device. Our results with a survival of 44%compare well with the other methods of insertion, andwe recommend the transthoracic route as an appropriatesecond choice for intraaortic balloon insertion.References

1. Pennington DG, Swartz M, Codd JE, et al: Intraaortic bal-loon pumping in cardiac surgical patients:a nine-year expe-rience. Ann Thorac Surg 36:125, 19832. McEnany MT, Kay H R, Buckley MJ, et al: Clinical experi-ence with intra-aortic balloon pump support in 728 pa-tients. Circulation 58:Suppl 1:124, 1978

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30 The Annals of Thoracic Surgery Vol 44 No 1 July 1987

3. Harvey JC, Goldstein JE, McCabe JE, et al: Complicationsofpercutaneous intra-aortic balloon pumping. Circulation64:Suppl 2:114, 1981

4. McCabe JE, Abel RM, Subramanian VA, Gay WA Jr: Com-plications of intra-aortic balloon insertion and counterpul-sation. Circulation 57769, 1978

5. Lee ME: Letter to the Editor. Ann Thorac Surg 20:237, 19756. Gueldner TL, Lawrence GH: Intraaortic balloon assist

through cannulation of ascending aorta. Ann Thorac Surg19238, 1975

7. Bonchek LI, Olinger GN: Direct ascending aortic insertionof the percutaneous intraaortic balloon catheter in theopen chest: advantages and precautions. Ann Thorac Surg32:512, 19818. Lamberti JJ,Cohen LH, Collings JJ: Iliac artery cannulationfor intra-aortic balloon counterpulsation. J Thorac Cardio-vasc Surg 67:976, 1974

9. Mayer JH: Subclavian artery approach for insertion of intra-aortic balloon. J Thorac Cardiovasc Surg 76:61, 197810. Bolooki H: Clinical Application of Intra-aortic BalloonPump, ed 1. Mt. Kisko, NY, Futura, 198411. Pollock JC, Charlton MC, Williams WG, et al: Intraaorticballoon pumping in children. Ann Thorac Surg 29:522,1980

12. Pappas G: Intra-thoracic intra-aortic balloon insertion forpulsatile cardiopulmonary bypass. Arch Surg 109:842, 1974

13. Shirkey AL, Loughridge BP, Lain K C Insertion of the in-

traaortic balloon through the aortic arch. Ann Thorac Surg21:560, 1976

14 . Macoviak J, Stephenson LW, Edmunds LH Jr, et al: Theintraaortic balloon pump : an analysis of five years experi-ence. A nn Thorac Surg 29:451, 1980

15. Meldrum-Hanna WG, Deal CW, Ross DE: Complications ofascending aortic intraaortic balloon pump cannulation.Ann Thorac Surg 40:241, 1985

16. Tchervenkov CI, Salerno TA: Preliminary experience with anew technique of insertion an d removal of the intra-aorticballoon pu mp in to the ascending aorta (letter to the editor).J Thorac Cardiovasc Surg 87475, 1984

17 . NuAez L, GilAguado M, lglesias A, Larrea JL: Transaorticcannulation for balloon pumping in a crowded aorta.Ann Thorac Surg 30:400, 198018. Phillips SJ, Zeff RH, Skinner J R Cannulation of ascendingaorta for IABP assist (correspondence). Ann Thorac Surg41:583, 1986

19. Isner JM, Cohen SR, Virmani R, et al: Complications of theintra-aortic balloon counterpulsation device: clinical andmorphologic observations in 45 necropsy patients. Am JCardiol45:260, 1980

20. Baciewicz FA Jr, Kaplan BM, Murphy TE, Neiman HL: Bi-lateral renal artery thrombotic occlusion: a unique compli-cation following removal of transthoracic intraaortic bal-loon. Ann Thorac Surg 33:631, 1982

Notice from the Southern Thoracic Surgical AssociationThe thirty-fourth Annual Meeting of the Southern Tho-racic Surgical Association will be held at the Boca RatonHotel and Club, Boca Raton, FL, November 5-7, 1987.There will be a $125 registration fee for nonmember phy-sicians except for guest speakers, authors and coauthorson the program, and residents. There will be a $50 regis-tration fee for attendees of the Postgraduate Course onSaturday, November 7, 1987. The Postgraduate Courseof the Southern Thoracic Surgical Association has beenexpanded to a full day and will provide in-depth cover-age of thoracic surgical topics selected primarily as ameans to enhance and broaden the knowledge of prac-ticing thoracic and cardiac surgeons.Applications for membership should have been com-

pleted by July 1, 1987, and forwarded to the SouthernThoracic Surgical Association, 111 East Wacker Dr,Chicago, IL 60601.The Southern Thoracic Surgical Association is ac-credited by the Accreditation Council for ContinuingMedical Education to sponsor continuing medical educa-tion for physicians.Gordon F . Murray , M.D.Secretary-TreasurerSouthern Thoracic Surgical AssociationBasic Science CenterWest Virginia UniversityMorgantown, WV 26506

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DOI:10.1016/S0003-4975(10)62350-81987;44:26-30Ann Thorac Surg

Horace MacVaugh, IIIWilliam McGeehin, Feroz Sheikh, James S. Donahoo, Michael J. Lechman and

Transthoracic Intraaortic Balloon Pump Support: Experience in 39 Patients

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Trans Thoracic Intraaortic Balloon Pump Support

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