Year : 2008 | Volume
: 11 | Issue : 1 | Page : 35--37
Use of intraaortic balloon counter pulsation in a patient with tortuous aorta
Murali Chakravarthy, Vivek Jawali
Wockhardt Heart Institute, Bangalore, Karnataka - 76, India
Wockhardt Hospitals, Bangalore - 560 076, Karnataka
The intraaortic balloon pulsation (IABP) catheter is commonly used to treat left ventricular failure. The abnormality of the descending thoracic and abdominal aorta is considered as a relative contraindication for its insertion. We present here a patient with acute myocardial infarction with a post-infarct ventricular septal defect who presented with left ventricular failure. During coronary angiography, tortuous abdominal aorta was noted and IABP catheter was inserted under fluoroscopic guidance to support the cardiovascular system. This case is reported to encourage discussion on the use of IABP catheters in patients with tortuous aorta and avoidance of events described.
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Chakravarthy M, Jawali V. Use of intraaortic balloon counter pulsation in a patient with tortuous aorta.Ann Card Anaesth 2008;11:35-37
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Chakravarthy M, Jawali V. Use of intraaortic balloon counter pulsation in a patient with tortuous aorta. Ann Card Anaesth [serial online] 2008 [cited 2020 Jul 11 ];11:35-37
Available from: http://www.annals.in/text.asp?2008/11/1/35/38447
A 75-year-old female, with a weight of 60 kg, height of 157 cm and a body mass index of 22.4 was admitted to the author's hospital with a history of chest pain for 2 days and dyspnoea at rest. She was diagnosed to have acute anteroseptal myocardial infarction. Transthoracic echocardiography revealed akinetic anterior wall, hypokinetic inferior wall and apical VSD. At the time of admission, the heart rate was 135/min, arterial pressure was 100/60 mm Hg, oxygen saturation was 90% and the patient was dyspnoeic. Mechanical ventilation was instituted and invasive arterial pressure (right femoral) and central venous catheters were inserted. A bolus of 3 mg of milrinone was administered followed by an intravenous infusion (0.5 µ g/kg/min). Heart rate decreased to 110/min, arterial pressure increased to 120/70 mm Hg and oxygen saturation increased up to 100%. Coronary angiogram was performed through the right femoral artery; the cardiologist observed tortuousity of the aorta during the procedure. The coronary angiography catheter was guided over a guide wire beyond the tortuousity by manoeuvring across the tortuousity with fluoroscopic guidance. An unusually longer length of coronary angiography catheter was required to engage the coronary arteries. Coronary angiogram revealed total occlusion of the left anterior descending artery, 80% occlusion of the obtuse marginal-1 artery and 100% occlusion of the posterior descending artery. Considering the immediate precedent condition of the patient and the tortuousity of the aorta, a 30 ml, 8.0 French IABP catheter (Arrow International, Inc, 2400, Bernville Road, PA, USA) was inserted (at the cardiac laboratory itself) to support the failing left ventricle using Datascope CS100 balloon pump (Datscope Corp., Mahwah, NJ, 07430, USA). Approximately 63 cm of the IABP catheter (its entire length was 70 cm) had to be inserted in the aorta in order to position the tip of the catheter at a point distal to the left subclavian artery. The gas-filled silhouette of the intraaortic balloon showed the tortuous abdominal aorta [Figure 1]; this image was obtained by sequentially placing the X-ray images obtained during the screening of the abdominal aorta). The diastolic augmentation of the arterial pressure was achieved with 100% of balloon volume (30 ml) at 1:1 frequency. The patient was then taken up for coronary artery bypass graft surgery and closure of the VSD after 2 h. The haemodynamic parameters were as follows: heart rate - 100/min, augmented arterial pressure - 130 mm Hg, systolic pressure - 80 mm Hg and diastolic pressure - 50 mm Hg. The infusion of intravenous medications was continued. She produced 450 ml of urine over a period of 2 h after institution of IABP therapy. Laboratory tests were normal. General anaesthesia was induced with 50 mg of intravenous propofol. Neuromuscular blockade was continued with Rocuronium and intraoperative analgesia was provided by intravenous boluses of 50 µ g of fentanyl at 3-h intervals. The TOE probe was inserted prior to commencement of surgery. The preliminary examination confirmed the findings of transthoracic echocardiogram and the surgery commenced. Heparinization was achieved with 300 units of heparin/kg and normothermic cardiopulmonary bypass was initiated with bicaval venous cannulation and antegrade aortic return. During cardiopulmonary bypass, the IABP was turned off as per our institutional protocol. Using warm antegrade potassium rich cardioplegia, coronary artery bypass graft to left anterior descending, obtuse marginal-1 and posterior descending arteries, using left internal mammary artery and saphenous vein grafts were performed. Through left ventriculotomy, apical ventricular septal defect was closed using a double woven Dacron patch. After the completion of the surgery, heart was deaired via the aortic root vent.
After reducing the venous return to the oxygenator and aortic flow, the IABP was turned on. Systolic ejections were observed on the arterial trace; however, despite augmenting with 30 ml at 1:1 frequency, the augmented pressure waveform was 70 mm Hg, while the systolic blood pressure was 90 mm Hg. It was presumed that the augmented arterial pressure was less than the systolic pressure because of low systemic vascular resistance that occurred immediately after the termination of cardiopulmonary bypass.  The TOE revealed the improvement of lateral and inferior wall motions; colour Doppler did not reveal residual shunt across the location of VSD. TOE failed to locate the tip of IABP catheter at its previous position; instead, the tip of the IABP catheter could be located at approximately 10 cm from left subclavian artery in the thoracic aorta. The sutures on the flanges of the catheter fixed to the skin on the anterior aspect of the right thigh were found to be intact. Under TOE guidance, the tip of the IABP catheter was repositioned after undoing the fixation sutures and insertion of a guide wire (0.032 in.) in the central lumen of the IABP catheter to stabilise it. Immediately, optimal diastolic augmentation (augmented arterial pressure - 130 mm Hg, systolic arterial pressure - 70 mm Hg) was observed. Cardiopulmonary bypass was terminated with an infusion of dopamine (10 µg/kg/min) Residual heparinization was reversed using 300 mg of protamine sulphate intravenously. The further course was uneventful.
The use of IABP support in patients with tortuous aorta has not been described. The manufacturers do not make any recommendation against the use of IABP catheter in such patients and suggest that the balloons are made of material that can adapt to aortic curvature. Nevertheless, the kinking of the catheter and improper diastolic augmentation of the arterial pressure may occur in such patients. Since IABP was indicated in the patient, it was decided to insert IABP using fluoroscopic guidance in the cardiac catheterisation laboratory itself because of the easy availability of fluoroscopy and various types and sizes of guide wires present there.
The displacement of the IABP catheter as seen in the present patient is unusual. The distal movement of the IABP catheter within the aortic lumen (with intact external fixation) may be caused by turbulence of blood flow caused by tortuousity of the aorta. The turbulence may be more than that in the normal aorta because of the tortuousity. In addition, an unusually long length of insertion (63 cm) was necessary in this patient. According to the author's experience, in Asian patients with a height of 160-170 cm, usually around 40-45 cm of the catheter is required in order to locate the tip of IABP catheter at a point distal to the left subclavian artery. However, in the present patient, an additional 23 cm of the balloon had to be inserted. The longer indwelling length may have predisposed the catheter displacement within the aorta.
A condition of augmented arterial pressure being lesser than the systemic arterial pressure may occur during one or more of the following conditions: severe vasodilatation, kinked catheter, inadequate volume of inflation and malfunction of the IABP equipment. Low systemic vascular resistance has been reported to occur immediately after the termination of cardiopulmonary bypass, which was suspected in this case.  In conclusion, the successful use of IABP catheter in a patient with tortuous aorta is described. The catheter may be prone to displacement and confirming the correct position of the catheter by the TOE before termination of the cardiopulmonary bypass is desirable.
|1||Brunvand H, Kongsgεrd E, Edvardsen T, Simonsen S, Pedersen TH, Karlsen HM, et al. Treatment of cardiac failure with an intra-aortic balloon pump. Tidsskr Nor Laegeforen 2006;126:2104-6|
|2||Kam PC, Hines L, O'Connor E. Effects of cardiopulmonary bypass on systemic vascular resistance. Perfusion 1996;11:346-50.|