Year : 2012  |  Volume : 15  |  Issue : 4  |  Page : 277--278

Invited Commentary


Murali Chakravarthy 
 Department of Anaesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bangalore, India

Correspondence Address:
Murali Chakravarthy
Department of Anaesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bangalore
India




How to cite this article:
Chakravarthy M. Invited Commentary.Ann Card Anaesth 2012;15:277-278


How to cite this URL:
Chakravarthy M. Invited Commentary. Ann Card Anaesth [serial online] 2012 [cited 2019 Dec 5 ];15:277-278
Available from: http://www.annals.in/text.asp?2012/15/4/277/101873


Full Text

The survey by Bignami et al.[1] focusing on the Italian perspective of use, discontinuation, and complications related to intra-aortic balloon pump (IABP) is timely. The authors confirm the expected results. IABP is one of the most versatile mechanical supports in the armamentarium of the cardiac anesthesiologists. There are differences in the way the IABP is inserted-with a sheath or sheath less; the way the IABP is removed-earlier to cessation of mechanical ventilation or after weaning from mechanical ventilation, or earlier to discontinuation of inotropes or afterward. Clinicians across the globe use various permutation and combination of these variables. In our experience, the final outcome of the patients is unrelated to the technique of weaning of IABP support and we believe it does not differ among various other centers. The outcome of the survey is expected to be similar, had it been performed anywhere else. In nutshell, the IABP use is not "standardized" [2] and the techniques of IABP circulatory support gives the users a degree of leeway.

IABP is inserted to thwart rapidly deteriorating left ventricular failure or on-going myocardial ischemia. What matters during these times when the heart is struggling is quick insertion of the IABP catheter whether percutaneous or via a sheath. The "holy grail" in these moments of imbalanced and unfavorable myocardial oxygen supply and demand is quick improvement in oxygen supply and reversal of excessive myocardial oxygen demand. The most important parameter at this moment is time and every second saved is extra second of better perfusion of the myocardium and therefore salvage of the ischemic myocardium. This manoeuvre also enhances tissue perfusion and oxygen delivery. Similarly, the method of weaning-whether reduction of balloon volume or frequency or inotropic agents or one or more of them may not affect weaning as long as the clinicians monitoring the patient quickly recognizes the onset of low-output syndrome and reverses the process of weaning by re-establishing "full augmentation." [3] In our experience, reducing one support at a time has been the golden rule in these situations. The discussion whether the patient should be rendered susceptible to the harmful effects of extubation is a moot one. At the same time, it is neither plausible to keep the counter-pulsation indefinitely nor to keep the inotropic medications or mechanical ventilation for long periods of time. The incidence of removal of IABP support on the first day in this publication [1] suggests that it was inserted in well-indicated patients at an appropriate time. The disrepute that IABP gained in the early days may have been due to wrongly indicated patient and inappropriate time.

The decreasing rates of complications associated with the use of IABP counter-pulsation in the Italian survey is a reflection of the global scenario. Bignami and colleagues could have evaluated the incidence of IABP insertions via the sheath, because it has been pointed out that the vascular complications would be higher in insertions via the sheath. [4],[5] Apparently, the vagaries of the physicians should less influence the use of IABP insertions and a global survey would be welcome to decide the optimal course. An outcome-related survey would offer more information and help the clinician decide whether a technique is better than the other.

References

1Bignami. E, Tritapepe. L, Pasin. L, Meroni. R, Corno. L, Testa. V, Landoni. G, Guarracino. F, Zangrillo. A. A survey on the use of intra-aortic balloon pump in cardiac surgery. Ann Card Anaesth 2012;15:274-7.
2Manohar VA, Levin RN, Karadolian SS, Usmani A, Timmis RM, Dery ME, et al. The impact of intra-aortic balloon pump weaning protocols on in-hospital clinical outcomes. J Interv Cardiol 2012;25:140-6.
3Meco M, Gramegna G, Yassini A, Bellisario A, Mazzaro E, Babbini M, et al. Mortality and morbidity from intra-aortic balloon pumps. Risk analysis. J Cardiovasc Surg (Torino) 2002;43:17-23.
4Severi L, Vaccaro P, Covotta M, Landoni G, Lembo R, Menichetti A. Severe Intra-aortic Balloon Pump Complications: A Single-Center 12-Year Experience. J Cardiothorac Vasc Anesth 2012;26:604-7
5Kocogullari CU, Emmiler M, Ayva E, Cekirdekct A. IABP-Related vascular complications: who is responsible-the patient, the surgeon or the sheath? Part I: sheath-related complications. Adv Ther 2008;25:225-30.