Original

Article A survey on the use of intra-aortic

This article is
accompanied
balloon pump in cardiac surgery
by an invited
commentary
by Dr. Murali Elena Bignami, Luigi Tritapepe1, Laura Pasin, Roberta Meroni, Laura Corno, Valentina Testa,
Chakravarthy Giovanni Landoni, Fabio Guarracino2, Alberto Zangrillo
Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milan, 1Department of
Anesthesiology and Intensive Care, La Sapienza University, Rome, 2Cardiothoracic Anaesthesia and Intensive Care
Medicine, University Hospital of Pisa, Pisa, Italy

ABSTRACT Intra-aortic balloon pump (IABP) is an established tool in the management of cardiac dysfunction in cardiac
surgery. The best timing for IABP weaning is unknown and varies greatly among cardiac centers. The
authors investigated the differences in IABP management among 66 cardiac surgery centers performing
40,675 cardiac surgery procedures in the 12-month study period. The centers were contacted through
email, telephone, or in person interview. IABP management was very heterogeneous in this survey: In 43%
centers it was routinely removed on the first postoperative day, and in 34% on the second postoperative
day. In 50% centers, it was routinely removed after extubation of the patients whereas in 15% centers
it was removed while the patients were sedated and mechanically ventilated. In 66% centers, patients
were routinely receiving pharmacological inotropic support at the time of removal of IABP. The practice
of decreasing IABP support was also heterogeneous: 57% centers weaned by reducing the ratio of beat
assistance whereas 34% centers weaned by reducing balloon volume. We conclude that the management
of IABP is heterogeneous and there is a need for large prospective studies on the management of IABP
in cardiac surgery.
Received: 18-01-12
Accepted: 02-06-12 Key words: Cardiac surgery, IABP, Intensive care, Intra-aortic balloon pump, Survey

INTRODUCTION fraction (EF), and systemic perfusion. IABP can

be placed before, during, or after surgery with
High-risk patients undergoing cardiac surgery, preoperative IABP insertion being associated
especially those with severe coronary artery with lower in-hospital mortality rates in high-
disease, are at high risk for myocardial risk patients when compared to those who
ischemia, arrhythmia, and heart failure. received it postoperatively.[1] IABP usually
Different therapeutic options are available to remains in place for a variable time after
support the heart in the perioperative period: surgery which usually ranges from 24 to 72
these include cardiovascular drugs such as hours; the duration of IABP support depends
inotropes, vasopressors, and vasodilators, on patients’ needs and/or local protocols.
Access this article online
devices such as intra-aortic balloon pump IABP can be used in combination with
Website: www.annals.in
(IABP) and ventricular assist devices, or a inotropes such as epinephrine, dobutamine,
PMID:
*** combination of the above. norepinephrine, levosimendan, etc.; however,
DOI:
there is no guideline whether to first perform
10.4103/0971-9784.101871 IABP increases myocardial oxygen supply the weaning from the IABP or from the
Quick Response Code: by increasing diastolic coronary perfusion inotropic or circulatory support drugs.[2] At
pressure, thereby increasing myocardial and the same time, there is no consensus on the
subendocardial perfusion, and decreases weaning modalities from IABP. The IABP
myocardial oxygen demand by reducing left support can be programmed to assist every
ventricular afterload. Additionally, IABP can beat (1:1) or less often (1:2, 1:4, or 1:8) [3]
also improve cardiac output (CO), ejection and weaning from IABP can be achieved by

Address for correspondence: Dr. Giovanni Landoni, Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital
Via Olgettina 60 Milan 20132, Italy. E-mail: [email protected]

274 Annals of Cardiac Anaesthesia    Vol. 15:4    Oct-Dec-2012

 Bignami, et al.: Intra-aortic baloon pump in cardiac surgery

reducing the ratio of assisted to non-assisted beats from removing IABP. Half of the centers performed weaning
1:1 to 1:2 or less. Alternatively, IABP weaning can be from IABP support when the patient was awake and
achieved by gradually decreasing the balloon volume, extubated, 15% during patient sedation, and 15% when
thus reducing the circulatory support and myocardial the patient was awake but intubated. Many centers
perfusion support during each cardiac cycle. The aim (20%) did not have a single strategy and considered the
of this national survey was to assess the management clinical condition of each patient, and the comorbidities
of IABP weaning, the combination of its use with drugs, to choose the best strategy. IABP was removed before
and the rate of complications associated with its use. weaning from inotropic support in 51% centers and after
weaning from inotropes in 46% centers, with few centers
MATERIALS AND METHODS
Table 1: Questionnaire on the use of IABP
administered to 66 Italian medical centers
The authors conducted a survey regarding elective use
Number of cardiac surgical procedures per year
of IABP during cardiac surgery in 66 Italian cardiac
Number of IABP placed per year
surgery centers. All centers answered a standardized Major complications related to IABP in the last year:
questionnaire [Table 1] through email, or on telephonic A – none
interview, or in person. The physician in charge of the B – at least one (specify)
intensive care unit (ICU) or one of his colleagues was IABP is usually removed:
contacted. In Italy, anesthesiologists and intensive care A – on the first day after surgery
specialists have the same curriculum and skills and they B – on the second day after surgery

work in operating rooms and in ICUs. The survey was C – other (specify)
Weaning from IABP and sedation/intubation:
therefore answered by anesthesiologists and intensive
A – the patient is sedated and intubated during weaning from IABP
care specialists. In less than half of the hospitals, the
B – the patient is awake, but intubated during weaning from IABP
postoperative ICU management of patients undergoing C – the patient is awake and extubated during weaning from IABP
cardiac surgery is performed by cardiac surgeons and D – other (specify)
in these cases the questionnaire was, in part, answered Weaning from IABP and inotropes:
by cardiac surgeons. IABP positioning was usually A – IABP is removed first
performed by cardiac surgeons in the operating rooms B – inotropic support is removed first
and by anesthesiologists/intensive care specialists C – other (specify)

in the ICU. IABP removal was usually performed by Concomitant use of IABP and inotropes:
A – it routinely occurs
anesthesiologists/intensive care specialists. Surgical
B – only if it is necessary
positioning and removal of IABP was rare, and if
Weaning from IABP is performed:
required, performed by surgeons. The above-described A– b
 y reducing the ratio of assisted to non-assisted beats from 1:1
practice is also the standard management at our center. to 1:2 to 1:4
Data are expressed as numbers and percentages. B – by gradually decreasing the balloon volume, keeping the ratio of
assisted to non-assisted beats 1:1
C – other (specify)
RESULTS
IABP: Intra-aortic balloon pump

All 66 medical centers answered to the questionnaire.

Table 2: Major complications related to IABP in a
Overall, 40,675 cardiac surgeries were performed in 12-month period in 66 centers
the 12-month study period (mean: 616 per center) with Complication Incidence of events
an average of 31 IABP positioned per year per center. Leg ischemia 20
No IABP-related complication was reported in 52% of Bleeding 3
centers. The IABP-related complications reported by Retroperitoneal hematoma 2
the remaining centers are listed in Table 2. The patient Femoral hematoma 2

with the acute thrombosis of the abdominal aorta died Acute thrombosis femoral artery 2
Acute thrombosis abdominal aorta 1
and this was the only IABP-related fatal complication.
Intestinal ischemia 1
Balloon rupture 1
IABP was routinely removed on the first (43%) or Aortic dissection 1
second (34%) postoperative day while 23% of centers Embolism 1
did not have fixed rules. All centers underlined that IABP entrapment in the iliac artery 1
patients’ clinical condition, hemodynamic status, and Blood in the balloon 1
echocardiography data were carefully evaluated before IABP: Intra-aortic balloon pump

Annals of Cardiac Anaesthesia    Vol. 15:4    Oct-Dec-2012 275

 Bignami, et al.: Intra-aortic baloon pump in cardiac surgery

(3%) having multiple strategies. IABP was always used 14-45% of patients receiving IABP therapy. If signs of
together with pharmacological inotropic support in the ischemia appear, the balloon should be removed. Other
majority of centers (66%) while 39% of centers used complications associated with IABP are arterial injury
one of the following agents only if clinically required: (dissection or perforation), peripheral embolization,
dobutamine, dopamine, epinephrine, norepinephrine, femoral artery thrombosis, infection, and bleeding.
enoximone, and levosimendan. Weaning from IABP Additionally, the balloon can break into the bloodstream
was performed in 57% centers by reducing the ratio of resulting in gas embolization.[7] Complication rate was
beat-to-beat assistance from 1:1 to 1:2 to 1:4, in other low in this survey with only one fatal complication
34% centers by reducing IABP balloon volume, and two occurring. The new devices and techniques of
other centers using the two techniques simultaneously, insertion have rendered this technique safe. Further,
one center turning the IABP off abruptly and two centers due to improvement in technology and use of new
using modified techniques. materials, IABP nowadays plays a very important role
in the management of ischemic and dysfunctional
DISCUSSION myocardium.[7]

The results of this survey confirm that the management A recent consensus conference identified IABP support
of IABP removal is heterogeneous among centers. among the few techniques/strategies capable of reducing
Apparently, in the absence of evidence-based medicine, perioperative mortality in the setting of cardiac
decisions are taken by the intensive care physicians surgery. [8] In fact, a recent meta-analysis of randomized
on the basis of tradition, physiological hypothesis, or controlled trials suggested that preoperative IABP can
personal opinions. Different management strategies reduce mortality in high-risk CABG patients.[1]
could be equivalent or one could be superior to the
other one. It is unknown whether different modalities CONCLUSIONS
of IABP weaning (reducing the ratio of beat assistance
or reducing the balloon volume) are equivalent in The IABP support was used in more than 1800
terms of clinically significant outcomes. Similarly, it patients in 66 centers including 40,675 cardiac surgery
is unknown whether removing the IABP on the first procedures performed in 1 year. The IABP management
or on the second postoperative day in patients with an was very heterogeneous in this survey. The weaning
uneventful postoperative course could either decrease from IABP support consisted of reducing the ratio of
costs and infections (if the correct approach is to remove beat-to-beat assistance or reduction in balloon volume.
it early) or decrease the risks of low CO and organ failure The IABP support was removed either on the first or
(if the right approach is to remove it later). second postoperative day, in awake and extubated
patients or in sedated and mechanically ventilated
Similarly, removing the IABP with the patient patients; the patients were either weaned from or
sedated and intubated could reduce pain and stress receiving inotropic support. Since IABP management
or, conversely, not allow the patient to have the IABP can either improve patients’ outcome or unnecessarily
support during extubation, probably the most stressful prolong ICU stay and iatrogenic complication, this topic
postoperative period. Should all patients with IABP should be further evaluated in prospective studies.
receive inotropic agents (with all the positive and
detrimental effects of these drugs)? Should we consider ACKNOWLEDGMENT
all inotropic agents harmful when meta-analyses of
randomized trials suggested that in the specific setting We are indebted to Zuppelli Paola for the help in data entry.
of cardiac surgery these drugs potentially reduce or
increase perioperative mortality?[4,5] An intriguing REFERENCES
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Invited Commentary

The survey by Bignami et al.[1] focusing on the Italian also enhances tissue perfusion and oxygen delivery.
perspective of use, discontinuation, and complications Similarly, the method of weaning—whether reduction of
related to intra-aortic balloon pump (IABP) is timely. balloon volume or frequency or inotropic agents or one
The authors confirm the expected results. IABP is or more of them may not affect weaning as long as the
one of the most versatile mechanical supports in clinicians monitoring the patient quickly recognizes the
the armamentarium of the cardiac anesthesiologists. onset of low-output syndrome and reverses the process
There are differences in the way the IABP is inserted— of weaning by re-establishing “full augmentation.”[3]
with a sheath or sheath less; the way the IABP is In our experience, reducing one support at a time has
removed—earlier to cessation of mechanical ventilation been the golden rule in these situations. The discussion
or after weaning from mechanical ventilation, or whether the patient should be rendered susceptible
earlier to discontinuation of inotropes or afterward. to the harmful effects of extubation is a moot one.
Clinicians across the globe use various permutation At the same time, it is neither plausible to keep the
and combination of these variables. In our experience, counter-pulsation indefinitely nor to keep the inotropic
the final outcome of the patients is unrelated to medications or mechanical ventilation for long periods
the technique of weaning of IABP support and of time. The incidence of removal of IABP support on
we believe it does not differ among various other the first day in this publication[1] suggests that it was
centers. The outcome of the survey is expected to inserted in well-indicated patients at an appropriate
be similar, had it been performed anywhere else. In time. The disrepute that IABP gained in the early days
nutshell, the IABP use is not “standardized”[2] and the may have been due to wrongly indicated patient and
techniques of IABP circulatory support gives the users a inappropriate time.
degree of leeway.
The decreasing rates of complications associated
IABP is inserted to thwart rapidly deteriorating left with the use of IABP counter-pulsation in the Italian
ventricular failure or on-going myocardial ischemia. survey is a reflection of the global scenario. Bignami
What matters during these times when the heart is and colleagues could have evaluated the incidence of
struggling is quick insertion of the IABP catheter whether IABP insertions via the sheath, because it has been
percutaneous or via a sheath. The “holy grail” in these pointed out that the vascular complications would be
moments of imbalanced and unfavorable myocardial higher in insertions via the sheath.[4,5] Apparently, the
oxygen supply and demand is quick improvement in vagaries of the physicians should less influence the
oxygen supply and reversal of excessive myocardial use of IABP insertions and a global survey would be
oxygen demand. The most important parameter at this welcome to decide the optimal course. An outcome-
moment is time and every second saved is extra second related survey would offer more information and help
of better perfusion of the myocardium and therefore the clinician decide whether a technique is better
salvage of the ischemic myocardium. This manoeuvre than the other.

Annals of Cardiac Anaesthesia    Vol. 15:4    Oct-Dec-2012 277

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