lntraaortic balloon counterpulsation ina community hospital*€¦ · intraaortic counterpulsation...

58 SINCH El AL CHEST, 79: 1, JANUARY, 1981

lntraaortic Balloon Counterpulsation in a

Community Hospital*lang B. Singh, M.D.; Pamela Connelly, R.N.; Stanley Kocot, M.D.;Peter Kotilainen, Ph.D.; Willard M. Daggett, M.D., F.C.C.P.; and

Mortimer I. Buckley, M.D., F.C.C.P.

Our experience with intraaortic balloon counterpulsa-tion in 41 patients documents the feasibility of a co-

ordinated aggressive therapeutic approach in patients

with potentially fatal complications of coronary artery

disease. The use of intraaortic balloon pump in a non-

The intraaortic balloon pump (IABP) was first

applied in experimental myocardial infarction in

1962.1 Most of the early clinical work in this field

was, however, not accomplished until 1971 to 1973.2

Intraaortic balloon counterpulsation has been shown

to improve myocardial oxygen supply by increasing

aortic perfusion pressure, and hence, coronary blood

flow, to decrease myocardial oxygen consumption by

decreasing afterload and to improve peripheral per-

fusion pressure without increasing the cardiac work

load.3 The earliest application of intraaortic balloon

counterpulsation was in the management of patientswith cardiogenic shock.4 As it became apparent that

the fate of the ischemic zone in myocardial inf arc-

tion depended upon the delicate balance between

myocardial oxygen demand and supply, and that

salvage of the ischemic myocardium was possible,

the hemodynamic effects of intraaortic balloon

counterpulsation seemed ideally suited for applica-

tion to high risk myocardial infarction patients. With

additional experience, the hemodynamic and meta-

bolic effects of counterpulsation were also found to

be desirable in the management of severe left ven-

tricular dysfunction after cardiac surgery,5 manage-

ment of unstable angina,8’7 and also for stabilizing

patients with myocardial infarction who continue to

have persistent evidence of ischemia.

The purpose of this report is to present our ex-

perience with intraaortic balloon counterpulsation in

a community hospital where, at present, inhouse

cardiac surgery is not available. This report is also

presented to establish the feasibility of providing

#{176}FromSt. Vincent Hospital, Worcester, and the Massachu-setts General Hospital, Boston MA.Presented in part at the 26th Annual Session, AmericanCollege of Cardiology, Las Vegas, March, 1977.

Manuscript received October 30; revision accepted February27.Reprint requests: Dr. Singh, St. Vincent Hospital, 25 Win-throp Street, Worcester, Mass 01605

cardiac surgical center has allowed hemodynamic support

in the critically ill, safety in angiography, appropriate se-lection of patients for surgery, and safe transportation toa cardiac surgery center when indicated.

immediate hemodynamic support to a group of crit-

ically-ill patients where it was possible to carry out

diagnostic angiography safely, and thus permit fur-

ther therapeutic decisions on the basis of those find-

ings.

PATIENT Cu.�ii�crEmsTIcs

Intraaortic counterpulsation was attempted in a total of 47

patients. This could be successfully performed in 41 patients.

In six patients, the balloon could not be inserted via the

ileofemoral vessels, primarily because of tortuosity of the

vessels and severe atherosclerotic lesions. Of the 41 patients

in whom intraaortic counterpulsation was successfully ap-

plied, 32 were men and 9 women, with an age range of 43 to74 years (mean age 57 years). The patients were divided

into the three following groups for analysis: Group A, com-prised of 16 patients in cardiogenic shock; Group B, 22

patients, 13 of which had acute myocardial infarction anddemonstrated recurrent ischemia within the first ten days

after admission; nine presented with a history of unstableangina but without evidence of recent infarction; and Group

C, three patients, two of whom had resistant ventriculararrhythmias and left ventricular failure with acute myocar-dial infarction. A third patient presented with noncoronarycardiogenic shock secondary to primary myocardial disease.

Msrrisovs

All patients in group A had hemodynamic monitoring

performed with Swan-Ganz catheterization. Intraarterialmonitoring was performed by cannulation of the radial ar-

tery, and cardiac outputs were obtained by the thermodilu-

lion method. Minimum criteria for cardiogenic shock weresystolic pressure of less than 90 mm Hg, urine output of lessthan 30 ml/hour, confusion, and cold, clammy skin. This was

further substantiated by a pulmonary capillary pressure of 20mm Hg or greater and cardiac index of 2.0 L/min/sq m or

less. However, cardiac output in five patients was not avail-able before the insertion of IABP. In group A patients with

cardiogenic shock, volume replacement with cohloids wasinstituted when the pulmonary capillary pressure was below20 mm Hg. Initial trial of vasopressor therapy was instituted

in all the patients. This, however, was not carried out forlonger than four hours in the patients who did not show

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CHEST, 79: 1, JANUARY, 1981 INTRAAORTIC BALLOON COUNTERPULSATION IN A COMMUNITY HOSPITAL 59

hemodynamic reversibility of shock state during that period

in the interest of providing early hemodynamic support tothese patients. Patients with cardiogenic shock secondary to

reversible cardiac arrhythmias were excluded from group A.

All patients in group B were initially treated with iso-

sorbide starting with 10 mg (orally) q4 hours with progres-sive increases in dosage to a maximally-tolerated level. Beta

blockade with intravenously administered propranolol was

instituted to achieve a heart rate of 60 beats per minute or

less, provided there was no evidence of left ventricularfailure or hypotension. Most of these patients had Swan-Canz

catheters placed, enabling us to give intravenous propranolol

at a dose of 0.1 mg/kg of body weight over the first 30minutes. The patients who were already receiving propra-

nolol had that drug increased to achieve maximal betablockade. However, in some patients, full trialof propranolol

was not possible in view of recurrent episodes of chest painwith objective evidence of ischemia and hemodynamic de-

terioration. The dose of propranolol in this group of patients

ranged from 160 to 320 mg/day. Significant elevation of

pulmonary capillary wedge pressure during an episode ofchest pain or ST segment elevation or depression on an EGG

recorded during pain was considered objective evidence ofrecurrent ischemia. Ten of the 22 patients demonstrated

elevation of the pulmonary capillary wedge pressure during

an episode of chest pain, and all others were documented tohave electrocardiographic changes during ischemic episodes.Eight patients had ST segment changes and pulmonary

capillary pressure elevation during chest pain.

The AVCO intraaortic counterpulsation system with a 30to 40 ml balloon was used in all patients, depending on the

size of the patient and the size of the available vessel. Thecatheters were all inserted via common femoral artery cut-down under local anesthesia. Most of these procedures were

carried out at bedside in the coronary care unit. The balloonwas positioned in the descending thoracic aorta, just below

the left subclavian artery origin. Balloon position was always

confirmed by fluoroscopy and chest roentgenogram. An intra-arterial catheter recording from a radial artery was used for

timing of balloon inflation and deflation. Intravenously admin-istered heparin, 4,000 IU every four hours, was used in the

initial patients in this study; later most of the patients

received 1,000 to 1,5(X) IU heparin by continuous intravenous

infusion. In addition to !ABP, pharmacologic support with

nitroprusside, dopamine, or both was instituted and continuedwhenever necessary. Cardiac catheterization and coronary

angiography were performed in a large majority of these

patients within 24 hours of insertion of the intraaortic balloon.

Further decisions regarding therapy were made, dependingupon the results obtained at cardiac catheterization. For the

Table 1-Group A, Shock

Age, Sex Admitting Diagnosis Coronary Anatomy Surgery Outcome

61, M Ant-Lat MI .. . . .. Died 2 hr

61, M Inferior MI . .. .. Died On IABP

57, M Inferior MI Severe three-vessel disease ... Weaned A & W 27 mo

65, F Ant-Lat MI ... ... Died 72 hr on IABP

60, M Acute inferior MI Severe two-vessel disease .. . Died 1 yr after weaning

48, M Anterior & inferiorMI (both acute)

Rt dominant high gradeprox. LAD mid RCA 90%

Double bypassLAD & RCA

Alive 22 mo

60, F Ant-Lat infarct LAD occluded, RCA

occluded midportion

... Weaned, died

48, M Anterior infarctRBBB-LAD

LAD 70% proximal,

circumflex 50% mid portion

.. . Weaned A & W 1 yr

74, F Acute anterior-lat.

infarctTotal occlusion of LAD ... Died 5 days

58, M Postero-inferior MI Three-vessel disease

akinetic ant wall

Severe mitral regurgitation

Double bypass

to LAD & RCA

mitral valve

15 mo A & W

68, F Ant-Lat MI (acute) . .. . . . Died 72 hr after weaning

59, M Ant-Lat MI .. . .. . Died 24 hr after weaning

48, M Anterior & inferiorMI (both acute)

Severe three-vessel

CAD, severe MR

Triple CABG

MVRDied 1 mo, post op

38, M Posterio inferior-lateral MI

Total occlusion dominant

circumflex artery- - . Weaned A & W 12 mo

62, M Acute anterior-

Lat old MISevere three-vessel

CAD. -. Weaned

Alive, died 2 mo

60, M Acute ant-lat

MI

LAD 80% proximal

RCA 50% mid portion

- -. Died 72 hr after weaning

CAD, coronary artery disease; RCA, right coronary artery; LAD, left anterior descending artery; MR, mitral regurgitation;MVR, mitral valve replacement


16

GROUP A - SHOCK

Survivors

/Medical & 13

/ NHospital Deaths

Surgical R,� 3 Survivors

60 SINGH El AL CHEST, 79: 1, JANUARY, 1981

Long Term Survivors 7/16 - 44�

Ficunx 1. Hospital course of patients in cardiogenic shock.

patients in cardiogenic shock, balloon dependency was deter-

mined by a phased gradual withdrawal of circulatory assis-tance before selecting patients for cardiac surgery. Fall in the

mean aortic pressure with rising wedge pressure and falling

cardiac output, thus suggesting any deterioration of leftventricular function curve, or recurrence of ischemic pain

was considered evidence of balloon dependency. Anatomicfeasibility for revascularization and balloon dependency wereconsidered indications for surgery.

RESULTS

Group A, Cardiogenic Shock (Fig 1)

Of the 16 patients in group A, 11 patients under-

went cardiac catheterization and coronary angiog-

raphy (Table 1). Six patients had severe three-vessel

coronary artery disease; three severe two-vessel dis-

ease; one total obstruction of the proximal left an-

terior descending artery; another total occlusion of a

dominant circumflex artery.

Anterolateral myocardial infarction was present in

nine patients; anterior and inferior myocardial in-

farction within three days of each other in two; and

posterior inferolateral myocardial infarction in five.

Three of the four patients with inferolateral myo-

cardial infarction also had a previous remote myo-

cardial infarction. Seven of the eleven patients

undergoing cardiac catheterization had a previous

documented infarction. The ejection fraction, (Table

2) in this group was 33.6 ± 3.1 percent, the left ven-

tricular end-diastolic pressure 17 ± 2.5 mm Hg.

Table 2-Group A, Shock

Ejection fraction:

Cardiac index on IABP:

33.6 ±3.1%

2.6 ±0.2 L/min/sq m

LVED: 17.0±2.5mm Hg

PCW before IABP: 21.4±2.8mm Hg

PCW 1 hr after IABP: 16.0±1.6mm Hg

Coronary arteriography

3 vessel2 vesselI vessel

N = 11

632

Cardiac index on hemodynamic support was 2.6 ±

0.2 L/ minI sq m. Pulmonary capillary wedge pres-

5 sure, before intraaortic balloon counterpulsation,

was 21.4 ± 2.8 mm Hg, and after an hour of intra-

aortic counterpulsation, dropped to 16 ± 1.6 mm

8 Hg. On the basis of the cardiac catheterization andangiographic findings, three patients were consid-

ered suitable for cardiac surgery. Two of these pa-

2 tients had severe mitral regurgitation and severe

three-vessel coronary artery disease. One of these

patients, with an acute posterior lateral myocardial

infarction, had a mean pressure of 60 mm Hg, with a

systolic pressure of 65 mm Hg and a diastolic pres-

sure of 55 mm Hg. He had a pulmonary capillary

mean pressure of 20 mm Hg and a cardiac index of

1.9 L/min/sq m. This patient had no urine output

for 24 hours prior to transfer to this hospital, in spite

of dopamine and diuretic therapy. Twenty-four

hours after IABP, his aortic pressure improved to 65

to 84/42 mm Hg, with 19 mm Hg diastolic aug-

mentation and a mean pressure of 65 mm Hg. Pul-

monary capillary pressure dropped to 12 mm Hg,

and cardiac index improved to 2.8 L/min/sq m. This

patient had severe three-vessel disease and severe

mitral insufficiency documented angiographically.

Coronary artery bypass grafts to the left anterior

descending and right coronary arteries and mitral

valve replacement were performed.

At 23 months postoperatively, the patient is in

AHA functional class 2 and is gainfully employed

as an engineer. A second patient with anterior and

inferior myocardial infarction with severe mitral

regurgitation had a mitral valve replacement and

single vessel graft to the left anterior descending

artery. He survived surgery, but died one month later

from renal failure. Another patient, a 42-year-old

man, considered balloon dependent, underwent

double coronary artery bypass graft to the left an-

terior descending and right coronary artery. He had

an ejection fraction of 30 percent. He is alive, 30

months after cardiac surgery. He is in functional

class 2 to 3. Of the 13 medically-treated patients,

there were eight hospital deaths and five patients

were weaned off the balloon with the assistance of

intravenously given nitroprusside and dopamine

which were gradually supplemented by vasodilators

administered orally in large amounts. Three of these

patients had inferior myocardial infarction, one an-

terior myocardial infarction, and one acute inferior

myocardial infarction with a remote anterior myo-

cardial infarction. The five hospital survivors have

been followed for a mean period of 14 months. One

patient is alive at 35 months (class 2 B), another at

24 months (class 2 C), a third patient died in the

12th month (class 2 C), and two patients are alive


CHEST, 79: 1, JANUARY, 1981 INTRAAORTIC BALLOON COUNTERPULSATIONIN A COMMUNITY HOSPITAL 61

9

GROUP B - ISCHEMIA

Vunstable angina

16

surgery

22

angiography

N13

M.I. with acute angina

6

All survived

weaned

FIGusz 2. Hospital course of patients in ischemia group.

one month after weaning from the intraaortic bal-

loon (class 2 B). The overall hospital survival in

group A with cardilogenic shock is 50 percent, that is,

eight out of 16 patients, and long-term survival is

seven out of 16 patients, calculated to 44 percent.

Five patients showed progressive deterioration, two

refused angiography, in two, angiography was not

carried out because of marked deterioration, four

died 2 to 72 hours on IABP, and one died immedi-

ately after weaning.

Group B, Ischemia Group (Fig 2)

This group included 22 patients with unstable

angina pectoris inadequately responsive to maximal

medical therapy. Thirteen of the 22 patients had

recent acute myocardial infarction with recurrent

unstable angina within three weeks after infarction.

All of the 22 patients (Table 3) in this group had

hemodynamic assessment and coronary angiogra-

phy. Six of the 22 patients had severe one-vessel

coronary artery disease (five LAD, one right coro-

nary artery), ten had severe two-vessel disease, and

six had severe three-vessel disease. The ejection frac-

tion when calculated (n = 17) preoperatively in this

group of patients was 53 ± 5 percent, and left

ventricular end diastolic pressure on IABP was 13 ±

1.7 mm Hg. The cardiac index was 2.5 ± 0.14

Table 3-group B, Ischemia

Ejection fraction: 53.0 ± 5.0%Cardiac index on IABP: 2.5 ±0.14 L/min/sq m

LVED: 13.0 ± 1.7 mm Hg

PCW before IABP: 10.5±1.3mm Hg

PCW 1 hr after IABP: 9.0 ± 1.6 mm Hg

Coronary arteriography 11 N =22

3 vessel 6

2 vessel 10

1 vessel 6

L/min/sq m. Pulmonary capillary wedge pressure

before counterpulsation was 9 ± 1.6 mm Hg (NS).

Sixteen of these patients were considered operable

after coronary angiography had been performed,

and following transfer to the Massachusetts General

Hospital, they had coronary bypass surgery per-

formed. There were no surgical deaths. One patient

with Prinzmetal angina suffered a perioperative

myocardial infarction. These patients have been fol-

lowed for a mean period of 15 months, ranging from

15 days to 35 months, and all are alive and well. Six

patients were weaned from IABP; all are alive at

this time receiving medical therapy. It was possible

to increase and optimize their medical regimen, and

hence, allowed time for stabilization. Five of these

patients had a proximal coronary artery lesion re-

sponsible for infarction and midportion or distallesion in another coronary artery. One patient had

severe three-vessel disease when he had to be

weaned off because of platelet depletion secondary

to associated heparin therapy. All of these patients

continue receiving medical therapy.

Group C

Two of the three patients in group C were treated

for left ventricular failure and ventricular ar-

rhythmias. Both patients were weaned from IABP

successfully. One died two months after hospital

discharge. He had presented to the hospital after a

massive anterolateral myocardial infarction, with a

history of previous inferior myocardial infarction.

Another patient with acute myocardial infarction

and intractable ventricular arrhythmias was weaned

successfully and is alive and well. Only moderate

reductions of PVCs were seen in both cases; how-

ever, no episodes of ventricular tachycardia occurred

when on IABP. The third patient, who received

IABP for noncoronary cardiogenic shock due to

advanced cardiomyopathy, also died six weeks later

at home. On angiography he was found to have

normal coronary arteries and a severely hypokinetic

left ventricle.

Complications

One patient continued with major arterial insuffi-ciency in one leg. Three patients suffered dissection

of the iliac vessels and descending aorta during

unsuccessful attempts at insertion. One patient re-

quired femoral artery thrombectomy two weeks

after weaning from the balloon. There were no

deaths related to any of the above complications and

insertion of intraaortic balloon. The complication

rate is 10 percent in the total population; however, in

the group where the intraaortic balloon was success-


62 SINCH ET AL CHEST, 79: 1, JANUARY, 1981

fully inserted, the complication rate is only 5 per-

cent.

DISCUSSION

Scheidt et al,8 in 1973, reported the results of a

cooperative clinical trial of intraaortic balloon coun-

terpulsation in patients with cardiogenic shock.

Their experience did not show any appreciable de-

crease in mortality from cardiogenic shock as a re-

sult of intraaortic counterpulsation. However, the

majority of their patients were in very advanced

stages of cardiogenic shock. Their reported hospital

survival of 17 percent in a population with a pre-

dicted 100 percent mortality appeared encouraging.

Wilerson et al#{176}described his experience with IABP

in 27 patients, 23 of whom were in cardiogenic

shock. Although nine of these patients were weaned

from circulatory assistance, only three were dis-

charged from the hospital. Only a small group of

eight patients underwent cardiac catheterization,

and only one of these patients survived. Dunkman et

al2 reviewed experience with IABP in 24 patients in

cardiogenic shock, and of these, only nine could be

weaned from pump support. Four patients left the

hospital as long-term survivors. Sanders et aP#{176}sug-

gested that intraaortic balloon counterpulsation in

cardiogenic shock and acute myocardial infarction is

an effective method for temporary reversal of the

shock state, and commented that, unless combined

with definitive surgical correction, salvage rate may

be low. Lefemine et aP1 reported their experience

with IABP in 94 patients. Fourteen patients were

treated for cardiogenic shock including four who

underwent surgery, resulting in a survival rate of 71

percent in cardiogenic shock victims. This is an un-

usually high number from a small series of patients.

Previous experience of other authors without sur-

gical intervention has varied from a low of 11 per-

cent to a high of 41 percent. In this series, there was

a 50 percent hospital survival in the cardiogenic

shock group (and one late death).

It is our opinion that continued experience with

intraaortic balloon counterpulsation has resulted in

the development of pertinent specific criteria for

selection of patients who can benefit from this form

of mechanical assistance. Patients with moderately

preserved left ventricular function and good opacifi-

cation of the distal coronary arteries on angiography

and significant mechanical lesions, such as mitral

insufficiency and ventricular septal defect,12 are

likely to benefit most from intraaortic counterpulsa-

tion, often combined with surgical correction. On

the other hand, patients with a large previous myo-

cardial infarction, previous episodes of left ventricu-

lar failure, or marked cardiac enlargement, are least

likely to benefit in the long run from intraaortic

counterpulsation. Balloon dependency in the latter

group of patients is high, and weaning is dilflcult.

Another probable reason for our success in the group

with cardiogenic shock is the fact that we were able

to wean some of these patients from IABP with

careful titration of dopamine and nitroprusside over

several days, after an initial period of intraaortic

counterpulsation. These patients were eventually

switched over to oral vasodilator therapy and then

weaned from intravenously administered vasodila-

tors. The long-term result in at least two of the three

patients in group A who underwent corrective sur-

gery is very rewarding.

In addition to the patients with cardiogenic shock,

another important indication for counterpulsation is

in patients with unstable angina refractory to maxi-

mal medical therapy. It was possible to stabilize all

of these patients on intraaortic balloon counterpul-

sation and then to study them without any mortality

or morbidity. Long-term follow-up of these patients,

as described, is very encouraging, and one can only

speculate whether it was possible to prevent cardio-

genic shock in some of these patients, particularly

the ones who had recurrent ischemia in areas other

than a recent myocardial infarction. Out of this

group, the patients undergoing surgery did so with-

out any mortality in the immediate postoperative

period. Reports that counterpulsation reduces the

extent and severity of ischemic injury and perhaps

opens dormant collateral vessels13’14 are promising,

and raise the possibility that early use of intraaortic

counterpulsation may be beneficial for patients who

sustain large myocardial infarction, and may mini-

mize infarct size and reduce eventual necrosis.

Intraaortic counterpulsation can be carried out in

a coronary care unit by a well-coordinated team. In

our institution, ICU nurses were trained and ac-

cepted responsibility of taking care of these patients.

Two critical care nurses and one biomedical engi-

neer provided the back-up support. The IABP inser-

tions were carried out by thoracic surgeons at the

bedside. The initial evaluation and the request for

insertion of intraaortic balloon originated from a

cardiac consultant. It is an effective tool for provid-

ing immediate hemodynamic support to these cri-

tically-ill patients. Cardiac catheterization and an-

giography can be carried out without any mortality

in this high risk group of patients. Safety of these

studies is enhanced by IABP. However, it is clear

that only a select group of patients in cardiogenic

shock are likely to benefit from this mode of therapy.

In an institution providing care to a large number of

patients with coronary artery disease, application of

intraaortic counterpulsation is also likely to reduce


CHEST, 79: 1, JANUARY, 1981 INTRAAORTIC BALLOON COUNTERPULSATION IN A COMMUNITY HOSPITAL 63

mortality and morbidity in patients with unstable

angina who are refractory to the usual forms of

medical therapy. Transportation of these patients to

a cardiac surgical center required the use of a spe-

cially-equipped ambulance. This ambulance is

equipped to provide at least 15 amperes of power at

110 volts. It should be able to accommodate

stretcher, balloon pump, ventilator and provide

power output for the above as well as intravenous

pumps. Coordination with the surgeon and the sur-

gical center are of extreme importance. The surgeon

is kept aware of the progress of a potential patient at

all stages, and upon arrival at surgical center, ap-

propriate arrangements for the patient are well

established according to the individual needs of the

patient. The patients were thus transferred without

interruption of ballooning. A critical care nurse

and resident accompanied the patient during trans-

portation.

CONCLUSION

This report documents our experience in aggres-

sive management of potentially fatal complications

of coronary artery disease at a medical center where

in-house cardiac surgery is not available. The use of

intraaortic balloon counterpulsation is an effective

and safe method for providing hemodynamic sup-

port and carrying out diagnostic angiography in

high risk patients. The results of angiographic and

hemodynamic studies can define a group of patients

who may benefit from surgical revascularization

procedures. When indicated, such patients can be

transferred safely with continuing IABP support to a

cardiac surgical center. This study establishes the

feasibility of a coordinated, aggressive approach to

the management of such patients and attempts to

define criteria which may result in more optimal

utilization of facilities where cardiac surgery is

available.

ACKNOWLEDGMENT: The authors are grateful to Clar-ence C. Dumais, M.D., Richard L. Bishop M.D., OscarStarobin, M.D., Daniel Miller M.D., and Eciward Budnitz,M.D., for allowing us to include their patients in this report.We are also thankful to Louis Anastasia, M.D., and GeraldCarroll, M.D., who performed intraaortic balloon pump in-sertion in all the patients reported; and other members of thecritical care team for their untiring efforts.

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