Decreasing incidence of critical limb ischemia after intra-aortic balloon pump counterpulsation

Perfusionist removal of intra-aortic balloon pump catheters improves efficiency without an increase in complication rates

INTRODUCTION

The intra-aortic balloon pump (IABP) is one of the most utilized cardiac assist devices. Patients receiving IABP therapy are typically managed in high acuity clinical care areas with limited bed space and high demand. Our center instituted a certified clinical perfusionist (CCP) led initiative to remove IABP catheters in order to reduce IABP therapy time, hasten removal and improve efficiency.

METHODS

The purpose of the study is to compare outcomes for IABP removal by a certified clinical perfusionist to a physician. The primary outcome measures were site hematoma score and limb related complications. A survey was submitted to bedside nurses, managers/patient care coordinators, CCP's and physicians. The IABP quality assurance database was interrogated for the study.

RESULTS

There were 350 patients eligible for inclusion. The cohort was well balanced between CCP (n = 284) and physician (n = 66) groups for patient demographics, indication, insertion specifics and type of medical intervention. The majority of patients had no bruise or hematoma with perfusionist (n = 246, 87%) or physician (n = 58, 88%) (p = 0.78) removal. The physician group demonstrated a higher rate of grade 3 hematomas (p = 0.03). There was no statistically significant difference between CCP and physician groups for limb complications and mortality. Survey results showed an improved efficiency in bed space allocation, physician workload and a decreased IABP support time.

CONCLUSION

There is no difference in limb complications between perfusionist and physician removal of IABP catheters. The survey demonstrate an improvement in resource allocation and efficiency. A perfusionist led IABP removal program can be done safely and may help improve program efficiency.

[Intra-aortic balloon counterpulsation placed through the subclavian artery as a bridge to heart transplantation. Case report]

Advanced heart failure is a major health problem for which heart transplantation or left ventricular assist devices are the only effective treatments. Intra-aortic balloon pump inserted using femoral artery access as a bridge to heart transplantation is still frequently used, but has the disadvantage of limiting the patient's movements, hence exposing him or her to the hazards of immobility and threatening the success of the procedure or hindering recovery. Access through the subclavian artery has become an attractive alternative since it doesn't impair the patient's mobility, and there is increasing evidence supporting its use. We present the first case of subclavian counterpulsation balloon implantation in a cardiovascular care center in Colombia.

The science of safety: complications associated with the use of mechanical circulatory support in cardiogenic shock and best practices to maximize safety

Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use. Multiple devices exist across a spectrum from modest to complete support, and each is associated with unique risks. In this review, we summarize existing data on complications associated with the three most widely used acute MCS platforms: the intra-aortic balloon pump (IABP), Impella systems, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We review evidence from available randomized trials and highlight challenges comparing complication rates from case series and comparative observational studies where a lack of granular data precludes appropriate matching of patients by CS severity. We further offer a series of best practices to help shock practitioners minimize the risk of MCS-associated complications and ensure the best possible outcomes for patients.

Vascular complications following intra-aortic balloon pump implantation: an updated review

Background:

The use of the intra-aortic balloon pump (IABP) as a support device remains controversial due to the fact that a number of studies have shown no benefit in end mortality whilst using this device. One of the reasons for this could be the increase in vascular complications when using the pump. Therefore, the aim of the present review was to assess the current literature available with regards to IABP vascular complications during the clinical situation.

Methods:

A literature search was performed, searching for IABP complications in adult human studies between 1990 and 2016.

Results:

A total of 20 reports were identified as fitting the criteria of this study. The majority of vascular complications were limb ischemia, bleeding or mesenteric ischemia. The overall incidence of vascular complications ranged from 0.94% to 31.1%. Diabetes, peripheral vascular disease and hypertension, as well as smoking were all identified as risk factors for complications following IABP. Furthermore, studies supported the use of sheathless balloon insertion to reduce the risk of complications.

Conclusion:

Major vascular complications, including limb and mesenteric ischemia as well as bleeding and hemorrhage, have been associated with IABP. However, the incidence of these complications was generally low. Further studies are still required to truly understand the risk/benefit associated with the use of IABP.

IABP before cardiac surgery: clinical benefit compared to intraoperative implantation

Background:

The aim of this study was to determine whether preoperative compared to intraoperative intra-aortic balloon counterpulsation (IABP) is advantageous regarding 30-day and 2-year survival in high-risk patients (acute myocardial infarction, severely impaired left ventricular ejection fraction (LVEF), low output syndrome) undergoing coronary surgery.

Methods:

In the years 2004 to 2008, 156 consecutive patients undergoing coronary surgery with IABP support (119 preoperative, 37 intraoperative IABP) were observed. Applying Fisher’s exact test, as well as Wilcoxon and median tests, possible group differences were evaluated. After univariate analysis, models of logistic regression and Cox-regression were built.

Results:

Preoperative hemodynamic state and risk profile of the two patient groups were comparable: patients with preoperative IABP showed a similar level of urgency (21.9% vs. 18.9% emergencies), cardiogenic shock (8.4% vs. 10.8%), inotropes (8.4% vs. 8.1%), impaired LVEF (30.3% vs. 29.7%) and ventilation (5.9% vs. 5.4%) compared to patients with intraoperative IABP. Nevertheless, patients with intraoperative IABP demonstrated a significantly higher 30-day mortality rate (37.8% vs. 5.9%) and 2-year mortality rate (54.0% vs. 18.1%) compared to patients with preoperative IABP. Logistic regression revealed that patients with intraoperative IABP have a 16-times higher 30-day mortality rate after coronary surgery (OR: 16.386, 95% CI: 4.858-55.266) than patients with preoperative IABP. Two-year mortality (OR: 9.317, 95% CI: 3.430 to 25.311) and survival time were significantly better in patients with preoperative IABP therapy.

Conclusion:

Considering the significant benefit for patients with preoperative compared to intraoperative IABP and the absence of vascular problems after IABP insertion, the results of this study indicate a more liberal indication for IABP in high-risk patients before coronary bypass surgery.