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Ann Thorac Surg 1996;62:408-409
© 1996 The Society of Thoracic Surgeons
DR SHLOMO GABBAY (Newark, NJ): I congratulate Dr Dietl and his co-workers for this excellent investigation. This study seems to offer convincing proof that we should be less reluctant to use the intraaortic balloon.
I would like to point out a misconception; most surgeons think that if the patient leaves the operating room with an intraaortic balloon, this represents a "failure"; they see it as a sign that maybe the operation did not go well. If we want to save lives, I believe this is the wrong attitude.
The results of this investigation show that if we think about inserting the balloon, it must be done immediately. I am sure many of you have noticed that when you use the balloon prophylactically because the patient is considered a high risk, that patient gets through the procedure better than the so-called low-risk patient. This anecdotal experience has been proved by this study. I have long wanted to conduct a similar study to prove this point and am delighted that it was done by your group. I suggest that inserting the intraaortic balloon is a "virtue" and not a sign of surgical mishap. Use of the intraaortic balloon might save lives and, according to this study, might save some money, too.
DR NOEL L. MILLS (New Orleans, LA): In any of your patients did you use thyroid hormone before you put them on the intraaortic balloon pump at the time of operation?
DR DIETL: We have used triiodothyronine in a few patients, usually before weaning from cardiopulmonary bypass. I cannot say whether it was beneficial or not because of the small number of patients in whom it was used.
DR MILLS: How many of you use triiodothyronine when you are in trouble before you put the patient on the balloon pump? It looks as though none of you do. Now, how many of you use triiodothyronine before you take off your gloves and go out to tell the family you are sorry, but you could not save the patient? There appear to be several of you.
I have one more point. I believe there were no complications insofar as the balloon pump was concerned; there was no ischemia, no fasciotomies, and no femoral femoral bypasses?
DR DIETL: In group A, 8.1% (3 patients) had vascular complications. One patient had an ischemic leg without pulses. The condition of the leg improved after the balloon was removed shortly after the operation. Another patient had severe hemorrhage from the femoral artery after balloon removal, and 1 patient had development of a pseudoaneurysm. Both required surgical intervention.
In group B, 14.3% of the patients (4/28) in whom the balloon was used had ischemic complications in the lower extremity. Two of them required thrombectomy of the femoral artery and a fasciotomy; 1 patient underwent thrombectomy and embolectomy, and another patient was simply observed after balloon removal. There were no amputations in either group.
DR ANTHONY L. MOULTON (Providence, RI): I have a suggestion for what may be an intermediate course in some of these patients who are potentially high risk. One of the things my colleagues and I do for patients with low ejection fractions is place a femoral artery line at the start of the procedure. We all know how difficult it is to predict the degree of reversibility of ischemic ventricular dysfunction. When completely revascularized, a number of these patients come off bypass reasonably well. Although you predicted that they would need a balloon pump postoperatively, they do extremely well without one. One of the advantages of having a femoral artery line already in place is that in a patient who is not coming off bypass well and has no palpable pulses, you can simply slide up a guidewire and put in the intraaortic balloon pump without any fuss. It certainly speeds up that insertion. If the arterial line is already in place and you do not need a balloon pump, you have not exposed the patient to the risk of the balloon itself.
DR ALFONSO CHISCANO (San Antonio, TX): Thank you so much, Dr Dietl, for your beautiful paper. I stress the importance of the timing of the intraaortic balloon insertions. If the patient has had a recent myocardial infarction and has an ejection fraction of 0.15 to 0.20, and if the cardiologist gives you the luxury, ask him or her to insert the balloon the day before operation. I am aiming at 12 hours. In my experience, patients seem to do better than if they have the balloon inserted just preoperatively or postoperatively.
DR DIETL: Thank you, Dr Chiscano, for your comments. The timing of prophylactic insertion of the balloon pump depends on the clinical presentation. If the patient has chest pain during or shortly after cardiac catheterization, the cardiologists usually insert the balloon, and we take the patient to the operating room the same day. However, if the patient has no pain during the study, we prefer to insert the balloon ourselves in the operating room, just before induction of general anesthesia, using local anesthesia in the groin. We start counterpulsation before induction, and we verify the position of the balloon with transesophageal echocardiography, after the patient is intubated.
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