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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
 
Tex Heart Inst J. 2005; 32(1): 61–69.
PMCID: PMC555827
Archival Article

RETROSPECTIVE ANALYSIS OF 286 PATIENTS REQUIRING CIRCULATORY SUPPORT WITH THE INTRAAORTIC BALLOON PUMP

For more than a decade, the use of the intraaortic balloon pump (IABP) has been a major tool for providing mechanical support to the patient with failing circulation. Initially, there was considerable hesitation on the part of many clinicians to employ mechanical devices. The utilization of IABP has been traditionally reserved for critically ill patients, and then only as a final desperate measure. This approach to mechanical circulatory support accounts for the substantial lag time between intraaortic balloon pump availability and its widespread use.

The IABP was first conceived and studied by Moulopoulos, Topaz and Kolff (1961-1962),1 and independently by Clauss, Missier, Reed, and Tice in 1962.2 Its further development and testing was sponsored by the Artificial Heart Program of the National Heart Institute beginning in 1966. Clinical studies were begun in 1967, and Kantrowitz reported the first clinical experience in 1968.3 In 1969 large scale clinical investigations of the IABP began with the organization of a cooperative study4 involving ten institutions. With the commercial availability of intraaortic balloons and balloon drive units, the number of institutions investigating the IABP and utilizing it clinically expanded rapidly.

Intra- and postoperative use of the IABP has now gained widespread acceptance in the management of high-risk operative patients with low output states caused by reversible ventricular dysfunction.5–6 Our primary experience with IABP has been with post-cardiotomy patients who, because of a low output state, cannot be weaned from cardiopulmonary bypass despite rigorous pharmacologic intervention.

MATERIALS AND METHODS

Patients requiring circulatory assistance in our institutions are placed in a group of adjoining suites in the recovery rooms designated for special procedures. A Circulatory Support Service,7 which was formed around a nucleus of clinical engineers, supervises the unit (Fig. 1). The objective is on-line hemodynamic monitoring of the critically ill post-cardiotomy patient during IABP support. Major components of the system include:

figure 17FF1
Fig. 1. An interdisciplinary staff of surgical, technical, and medical consultants involved in our Circulatory Support Service.
  1. A Hewlitt-Packard 5690B computerized catheterization system with videomonitor, a system controller, remote terminal, and digital plotter;
  2. A Hewlitt-Packard 7754B 4-channel thermal recorder and 8848 amplifier system with preamps;
  3. A Hewlitt-Packard 3955D 7-channel magnetic tape recorder;
  4. A Hewlitt-Packard 7758B 8-channel thermal recorder, and
  5. An Edwards Laboratories 9510 cardiac output computer.

A diagram of the patient monitoring system is shown in Figure 2.

figure 17FF2
Fig. 2. Block diagram of intraaortic balloon pump (IABP) patient data acquisition system located in the Texas Heart Institute Intensive Care (Circulatory Support) Unit.

In the operating rooms, after insertion of the intraaortic balloon, an Edwards Laboratories 93A-118-7F Swan-Ganz flow-directed quadruplelumened catheter is inserted through either antecubital, subclavian, or internal jugular vein* with continuous pressure and electrocardiographic monitoring. Selected measurements of right atrial, pulmonary artery and pulmonary capillary wedge pressures, mixed venous oxygen saturation and cardiac output/index determinations are obtained hourly, or more oft-en when indicated, throughout the course of post-cardiotomy IABP support.

PATIENT POPULATION ANALYSIS

Since 1972, 286 patients have been supported by the IABP in our institutions. This number is compared to the total number of adult cardiotomy patients in Figure 3.

figure 17FF3
Fig. 3. Comparison of total surgical patient population with number of intraaortic baloon pump (IABP) patients.

In October of 1975, a long-term prospective study of these patients was initiated. A data base consisting of patient characteristics and serial hemodynamic data was established, and all patients supported by IABP were entered into the data base. (Tables I and II present the preliminary data of 247 patients.)

From the analyses of patient population data, several important trends have appeared. Since its clinical introduction in this institution in 1972, the number of patients undergoing IABP has steadily grown from less than 0.5% of the total surgical population to nearly 3.0%o. Earlier utilization of IABP and the accumulation of experience with pre-, intra-, and postoperative patient management techniques have contributed greatly to the significant improvement in patient survival.

In addition, the number of IABP patients discharged from the hospital has shown marked improvement, from 29%to in 1975 to 63% for the first nine months of 1977. The percentage of males and females that required IABP closely paralleled the incidence of males and females with coronary artery disease. Thus far in 1977, males requiring balloon pump assistance outnumber females four to one. Through the years, however, the percent survival for males has remained consistently and significantly higher than females. There has been no significant change in the mean age in the IABP population.

The instances of IABP usage were as follows: Sixty-seven percent of patients required IABP support immediately following cardiopulmonary bypass; 12% required IABP support during the early postoperative period (first three days); acute myocardial infarction cases accounted for 11%; and preoperative elective IABP support occurred in 6% of the patients.

Examination of the duration of IABP support shows that nonsurviving patients usually expire within the first 24 hours of assistance. Survivors require support for variable periods of time, from 12 to 140 hours, with a mean of 61 hours.

HEMODYNAMIC ASSESSMENT

Recently, we have begun an in-depth analysis of the actual hemodynamic effectiveness of counterpulsation via IABP. From clinical studies,8–10 we have obtained data that delineates the quantitative changes brought about by actuation of balloon pumping. In addition to the obvious effects on left ventricular parameters, we have studied and documented similar effects on right ventricular dynamics. Serial “on-off” studies were accomplished in representative patients and mean values for heart rate (HR—beats/min), cardiac index (CI—L/min/m2), stroke volume index (SVI—ml/beat/m2), left ventricular minute work ind.ex (LVMWI—kgm/min/m2), right ventricular minute work index (RVMWI—kgm/min/m2), systemic and pulmonary vascular resistance (SVR, PVR—dynes•sec•cm−5), pulmonary arteriolar resistance (PAR-dynes•sec•cm−5), pulmonary artery, pulmonary capillary wedge, right atrial and aortic pressures (PA, PCW, RAP, AoP—mm Hg) were obtained. The results are summarized in Table III.

Table thumbnail
TABLE III. Serial “ON-OFF” Studies

In addition to effecting immediate decreases in heart rate, left ventricular end-diastolic pressure, mean l.eft atrial pressure and modest increases in cardiac output (left ventricular functions), these results indicate that IABP actuation also produces instantaneous changes in right ventricular performance parameters, i.e., consistent decreases in RAP (right ventricular preload), PAP and PVR (major determinants of right ventricular afterload). All of the above hemodynamic effects were noted without significant changes in mean aortic pressure.

Further studies indicate that the hemodynamic effectiveness of IABP is dependent upon the level of myocardial recovery or deterioration in th.e postcardiotomy/myocardial infarction patient. The observed effects of IABP were inversely r.elated to the level of intrinsic myocardial function (CI) and directly related to the level of peripheral vascular resistance.

SUMMARY AND CONCLUSION

The intraaortic balloon pump patient characteristics of 286 patients treated at St. Luke's Episcopal Hospital-Texas Heart Institute are reported. IABP usage has increased sixteen-fold since its inception in 1972. The age distribution of these patients is depicted in Figure 4. Few patients under 30 and-over 70 years of age have been treated. Over half of those from 30 to 69 years of age who were supported by IABP survived. Eighty percent of the patients were male, paralleling the higher incidence of coronary artery disease among males. Surgical patients comprised 90%0 of IABP treated patients, reflecting this institution's emphasis on surgical treatment of acquired cardiovascular lesions. Figure 5 summarizes our experience.

figure 17FF4
Fig. 4. Distribution of intraaortic balloon pump (IABP) patients by age group.
figure 17FF5
Fig. 5. Summary of patient ratios (male/female; medical/surgical; and survivor/nonsurvivor) based on 286 patients undergoing intraaortic balloon pump (IABP) support.

Overall, our survival rate has been 48%o, with 58%o survival rate over the last 24 months, and 63% over the last 12 months.

Footnotes

*French 8 Introduces System, No. 501-608, Cordis Corporation, Miami, Florida 33137.

This article has been reprinted from Cardiovascular Diseases: Bulletin of the Texas Heart Institute 1977;4:428–36.

REFERENCES

1. Moulopoulos SD, Topaz S, Kolff WL: Diastolic balloon pumping (with carbon dioxide) in aorta: Mechanical assistance to failing circulation. Am Heart J 63:669, 1962 [PubMed]
2. Clauss RH, Missier P, Reed GE, Tice D: Assisted circulation by counterpulsation with intraaortic balloon: Methods and effects. Paper presented at the Annual Conference on Engineering in Medicine and Biology, Chicago, 1962
3. Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman J Jr: Initial clinical experience with intraaortic balloon pumping in cardiogenic shock. JAMA 203(No. 2):113, 1968 [PubMed]
4. Scheidt S, Wilner G, Mueller H, Sum;mers D, Lesch M, Wolff G, Krakaucr J, Rubenfire M, Fleming P, Noon G, Oldham N, Killip T, Kantrowitz A: Intraaortic balloon counterpulsation in cardiogenic shock. N Engl J Med 288:979, 1973 [PubMed]
5. Webb WR: Intraaortic balloon pumping. Ann Thorac Surg 21:571, 1976 [PubMed]
6. Kaiser GC, Marco JD, Barner HB, Codd JE, Laks H, Willman VL: Intraaortic balloon assistance. Ann Thorac Surg 21:487, 1976 [PubMed]
7. Hibbs CW, Edmonds CH, Slogoff S, Norman JC: Circulatory support service: A new paradigm in intensive care. From the Eighth Annual Conference on Advanced Medical Systems, The Third Century, Vol. I Published by the Society for Advanced Medical Systems, Chevy Chase, Maryland, 1977, p 15
8. Holub DA, Igo SR, Johnson MD, Brewer MA, Hibbs CW, Fuqua JM, Edmonds CH, Trono R, Winston DS, Norman JC: Changes in right ventricular function associated with intraaortic balloon pumping (IABP) in the cardiogenic shock patient. Clin Res 25(4):553A, 1977
9. Holub DA, Brewer MA, Johnson MD, Hibbs CW, Trono R, Edmonds CH, Fuqua JM, Igo SR, Norman JC: Hemodynamic effectiveness of IABP during myocardial recovery or deterioration in the post-cardiotomy/myocardial infarction patient. J Assoc for Advancement of Medical Instrumentation (in press), 1977
10. Norman JC: An intracorporeal (abdominal) left ventricular assist device [ALVAD], XXX: Clinical readiness and initial trials in man. Cardiovascular Diseases, Bulletin of the Texas Heart Institute 3:249, 1976 [PMC free article] [PubMed]

Articles from Texas Heart Institute Journal are provided here courtesy of Texas Heart Institute