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Ann Thorac Surg 2002;73:887-891
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Current results with intraaortic balloon pumping in infants and children

Kerrie A. Pinkney, MD, MPHa, L. LuAnn Minich, MDa, Lloyd Y. Tani, MDa, Gregory B. Di Russo, MDb, L. George Veasy, MDa, Edwin C. McGough, MDb, John A. Hawkins, MDb*

a Departments of Pediatrics and Surgery, Primary Children’s Medical Center,Salt Lake City, Utah, USA
b Departments of Pediatrics and Surgery, University of Utah, Salt Lake City, Utah, USA

Accepted for publication November 15, 2001.

* Address reprint requests to Dr Hawkins, Cardiothoracic Surgery, Primary Children’s Medical Center, 100 North Medical Dr, Salt Lake City, UT 84113, USA
e-mail: jhawkins{at}med.utah.edu


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Intraaortic balloon pumping (IABP) is useful for support in patients with moderate left ventricular dysfunction. IABP is usually timed with the R wave of the electrocardiogram. We have utilized M-mode echocardiography timed IABP in children with left-side heart failure since 1994. Electrocardiogram timing seems inappropriate for children, who have much higher heart rates. We describe our experience with children who underwent IABP therapy before and after 1994, when echocardiographic timing was instituted.

Methods. We reviewed records of 29 children who underwent IABP for all indications at Primary Children’s Medical Center since 1988.

Results. Overall survival was 62.1% (18 of 29) in this series. Survival was similar for infants (odds ratio = 2.0, 95% confidence interval = 0.29 to 14.31, p = 0.43) and older children. Survival was similar in the echocardiography era when compared with the electrocardiogram era (odds ratio = 2.4, 95% confidence interval = 0.56 to 10.4, p = 0.44).

Conclusions. IABP is a useful means of support in children with left ventricular dysfunction. M-mode echocardiography is effective in triggering IABP. The sample size in this study is too small to detect a mortality rate difference.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
In the adult patient intraaortic balloon pumping (IABP) is a standard therapeutic tool for managing acute left ventricular dysfunction after myocardial infarction or cardiac surgery [1]. Support for the failing pediatric myocardium is logistically difficult, however. Support has focused on the use of extracorporeal membrane oxygenation (ECMO) and in some instances left ventricular assist devices. The use of IABP in infants and children remains limited for several reasons including balloon availability, questions of efficacy due to aortic distensibility in children, and difficulty of balloon timing with the rapid heart rates of pediatric patients [2, 3]. Isolated reports and laboratory work suggest the failing pediatric myocardium can benefit from aortic counterpulsation, particularly when close attention is paid to balloon timing [4–6]. We have utilized IABP in children since 1981, largely in the absence of a left ventricular assist device or ECMO program. We sought to review our current experience with intraaortic balloon counterpulsation in infants and children since 1988.


   Patients and methods
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
We reviewed the records of all patients who underwent intraaortic balloon pumping at Primary Children’s Medical Center from July 1988 through December 2000. Results for patients who underwent intraaortic balloon pump therapy at our institution from 1981 through 1987 have been previously published and will not be reviewed here [7]. This study was reviewed and approved by the University of Utah Health Sciences Institutional Review Board. Each patient’s record was reviewed for diagnosis, indication for insertion (postoperative, medical, or bridge), age, weight, duration of therapy, timing method, survival, and complications. Statistical analysis was performed using the standard measures of odds ratio (OR) and Fisher’s exact test.

All 29 patients were mechanically ventilated and had refractory low cardiac output requiring at least two inotropic agents. Ages of all patients ranged from 1.7 months to 18.5 years (mean = 5.7 ± 5.3 years) and weights ranged from 4.3 kg to 56 kg (mean = 17.8 ± 13.5 kg). The median age of the patients was 4.02 years and the median weight was 12.9 kg. Twelve patients were less than 3 years of age and 8 were less than 1 year of age (infants). Diagnoses and indications are included in Tables 1, 2, and 3.


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  		Table 1. Results of Intraaortic Balloon Pump (IABP) Placement in 29 Children, 1988 to 2000

 

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  		Table 2. Survival Among Patients With Medical Indications for Intraaortic Balloon Pump Placement

 

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  		Table 3. Survival Among Patients With Postsurgical Indications for Intraaortic Balloon Pump Placement

 
General indications for balloon pump use
Patients in our institution are considered eligible for IABP therapy if they have a condition that is deemed reversible and if despite maximum noninvasive support, including pharmacologic support, they persistently demonstrate any or all of the following: hypotension despite maximal vasoactive medications, persistent acidosis (pH < 7.25), low urinary output ( < 1 mL · kg-1 · h-1), or clinical evidence of poor perfusion. Echocardiographic indicators of low ejection fraction and shortening fraction are not used alone but in combination with the patient’s entire clinical picture to determine the need for IABP. Patients with terminal illnesses or cardiac lesions that are incompatible with life are not considered eligible for this therapy.

Intraaortic balloon catheters and pump
Pediatric IABP catheters from the Datascope Corporation (Paramus, NJ) were used in all patients. Pediatric catheters differ from adult catheters in three ways. Pediatric catheters are smaller, do not contain a central pressure monitoring lumen, and are not prewrapped. The guidelines for choosing an appropriate size catheter have been previously published [3, 8, 13]. In general, a balloon that approximates 50% of the normal predicted stroke volume for each patient is appropriate. A standard Datascope Model 90 console was used for all patients and included a pediatric limiting chamber.

Technique of balloon placement
Pediatric catheters are generally inserted through a groin incision that provides direct common femoral artery visualization. All catheters in this series were routinely inserted through the femoral approach. The exact technique has been previously published [8]. Briefly, the common femoral artery was exposed through a small, vertical groin incision. The balloon catheter was placed through a 3.5 mm or 4 mm diameter short section (1 to 2 cm) of expanded polytetraflouroethylene graft material. The balloon was then threaded into the descending aorta into the proper position and confirmed by chest radiograph. The polytetraflouroethylene graft was sewn to the arteriotomy using 6-0 polypropylene suture (Fig 1). After hemostasis was achieved the patient was started on a continuous heparin infusion to maintain a partial thromboplastin time of 40 to 60 seconds.



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  		Fig 1. Operative technique for femoral artery insertion of intraaortic balloon pumping catheter. The common femoral artery is isolated through a vertical groin incision. The balloon catheter is inserted through a sidearm graft of polytetraflouroethylene. This graft is sewn to a longitudinal arteriotomy in the femoral artery.

 
Timing of the balloon pump
Before 1994 we utilized the standard method of balloon pump timing by triggering with the R wave from the electrocardiogram (ECG). The inflation and deflation points were then adjusted to maximize afterload reduction and diastolic augmentation [8]. Since 1994, we have used M-mode echocardiography to time balloon inflation and deflation. This method has been reported previously both clinically and in an experimental model [4, 5]. The transducer was positioned parasternally to obtain simultaneous images of both the aortic valve leaflets and the balloon. As the image was viewed the balloon inflation and deflation points were adjusted to coincide more accurately with aortic valve closure and opening (Figs 2, 3).



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  		Fig 2. M-mode echocardiogram from a parasternal transthoracic approach during intraaortic balloon pumping. Note that balloon inflation (I) occurs with aortic valve (AoV) closure (C) and balloon deflation (D) occurs with aortic valve opening (O)

 


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  		Fig 3. Arterial tracing from a child on intraaortic balloon pumping at a 1:2 ratio. The assisted beat shows excellent afterload reduction and diastolic augmentation in the distensible pediatric aorta.

 
Weaning from IABP
Weaning from IABP therapy began at physician discretion when pharmacologic support had been substantially reduced or weaned to none. Two-dimensional echocardiography was used to aid in the decision to wean. The improvement in left ventricular ejection phase indices such as shortening fraction and ejection fraction were used as guidelines. Weaning generally occurred over a 24-hour to 48-hour period depending on patient status. Before catheter removal the pump was systematically taken from 1:1 (inflation: QRS) frequency to 1:2 then to 1:3 over the weaning period. The groin incision was reopened and the IABP catheter was removed while simply ligating the sidearm polytetraflouroethylene graft. If clot was found or if no pulse was detectable in the ipsilateral foot, an embolectomy was performed to remove clot from the artery. The balloon was removed at the patient’s bedside.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Overall 62.1% of the patients (18 of 29) in this series were successfully weaned from the IABP and subsequently discharged home. All discharged patients are alive and mean follow-up is 4.9 ± 4.4 years. Duration of IABP therapy ranged from 3 hours to 10 days (mean 4.4 ± 2.9 days). The median duration of IABP therapy was 5 days. There was no significant difference in survival between male and female patients (p = 0.69). Sixteen postoperative patients required aortic counterpulsation. Eight of these patients had aortic counterpulsation started in the operating room and the remaining 8 had balloon placement in the intensive care unit within 12 hours of operation. Of the 13 patients who had the IABP placed for medical reasons, 7 underwent simultaneous listing for cardiac transplantation.

Early survival and hospital discharge were not affected by patient age. Survival was better among patients undergoing IABP for all indications for longer than 1 day (24 hours) and approached statistical significance (OR = 6.7, 95% CI = 0.78 to 70.1, p = 0.07) but this finding may be reflective of the overall severity of illness among this group. Survival was slightly less for infants, with 4 of 8 patients (50%) surviving as compared with 14 of 21 children more than 1 year of age (66.7%; OR = 2.0, 95% CI = 0.29 to 14.3, p = 0.43). Survival was slightly worse in those with IABP placed postoperatively (9 of 16, or 56.3%) as compared with those with IABP placed for medical reasons (9 of 13, or 69%, OR = 1.5, 95% CI = 0.34 to 6.61, p = 0.71). Survival was not statistically better in the echocardiography-timed era (12 of 17, or 70.6%) as compared with the standard ECG triggered timing era (6 of 12, or 50%; OR = 2.4, 95% CI = 0.56 to 10.4, p = 0.44). Three of the 4 deaths in the medical group occurred in patients listed for transplant who did not undergo transplantation owing to lack of donor availability. Complications occurred in 2 patients (2 of 29, or 6.9%). Complications included sepsis in 1 patient awaiting transplantation and transient limb ischemia in 1 patient. Neither complication required intraaortic balloon pump removal.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Intraaortic balloon counterpulsation is routinely used in the adult population and offers a safe and effective means of supporting the left ventricle with moderate dysfunction [1]. The use of IABP in infants and children, however, has remained limited and has had variable success. The reasons for this variability have been in part due to the technical difficulty of inserting the IABP in the infant or small child and the lack of commercially available catheters that can be inserted percutaneously in this group. The balloon has been thought to be less effective in the pediatric population because of the greater distensibility of the pediatric vasculature [2]. Also, in contrast to adults children frequently have biventricular failure and the IABP is only helpful for left ventricular dysfunction.

We have had a long-term interest in the use of pediatric balloon pumping at our institution since we began using IABP in 1981 [3]. Because we do not have a ventricular assist device or ECMO program at our institution, we have been in a unique situation to review the results of IABP in children over a long period of time. Echocardiographic timing was introduced at our institution in 1994 in an attempt to improve augmentation over that obtained with more traditional timing methods [5]. This current report chronicles one of the largest pediatric IABP experiences and expands upon our initial report of echocardiographic timing in 1997.

The current results from the last decade with survival of 62% approaches the survival rate seen in adult IABP series of nearly 80% [8]. Patient survival in our series compares favorably with other pediatric series [2, 3, 6, 8, 10]. Pollock and colleagues [2] and subsequently del Nido and associates [11] reported results of series in which, respectively 43% and 37% of patients were long-term survivors [2, 11]. Infants tended to do worse than older children [2, 11]. Park and associates [10] reported similar results with 4 of 9 children (44%) surviving.

The indications for IABP use then were expanded to include medical causes of ventricular failure and the use of IABP as a bridge to transplantation [10]. Recently Akomea-Agyin and associates [6] reported results in a series of 14 infants and children. They reported long-term survival in 50% of infants and 57% of both infants and children. Our early experience with IABP reported similar results to these authors with 35% to 50% long-term survival [3, 8].

These series, as well as that from our institution before 1994, utilized standard ECG timing methods for IABP inflation and deflation. Physiologic differences between children and adults necessitate more accurate timing methods. As demonstrated in our laboratory successful augmentation of cardiac output with reduction in left atrial pressure is not possible unless central aortic pressure can be measured and utilized for adjusting inflation and deflation points after ECG triggering [4, 12]. With traditional ECG timing, adjustments are made based upon judgments of augmentation from radial artery line tracings rather than central aortic pressure measured from the balloon catheter’s central lumen. Reports from our laboratory have demonstrated large errors in timing pediatric balloon counterpulsation using this method [4]. Radial artery tracings have been shown to deviate as much as 120 ms from the central aortic pressure tracing. This deviation when combined with the rapid heart rates of pediatric patients can translate into large errors [12]. The echocardiographic timing technique first reported in 1997 offers a more accurate method of balloon timing with aortic valve closure and opening [5]. This series from the laboratory demonstrates that more accurate timing translates into improved afterload reduction and augmentation.

Complications in our patients over the last 12 years have been few. In addition to our complications of sepsis and transient limb ischemia, others have reported complications of balloon rupture, vessel perforation, thrombocytopenia, aortic dissection, and mesenteric, renal, or cerebrovascular ischemia [2, 13].

Some report the use of IABP in children for specific cardiac problems including support for left ventricular dysfunction after repair of anomalous origin of the left coronary artery and the Fontan procedure. Nawa and colleagues [14] reported successful use of IABP in 1 of 3 children after the Fontan operation; and del Nido and colleagues [11] reported only 1 survivor out of 9 children undergoing the Fontan procedure. We have had experience in only 2 children with IABP after the Fontan procedure and both children survived. We would caution against the widespread use of IABP after the modified Fontan procedure. IABP should be used in this group only when the patient has primarily ventricular dysfunction rather than the low cardiac output state typically seen due to Fontan physiology with elevated right-sided pressures and good ventricular function.

Perhaps some of the reluctance for the use of IABP in children stems from the biventricular dysfunction seen after repair of congenital cardiac lesions, as IABP is only truly effective for moderate degrees of left ventricular dysfunction. Support for this observation is that IABP appears particularly helpful in those children with anomalous origin of the left coronary artery and left ventricular dysfunction. Akomea-Agyin and associates [6] have recently shown benefit in 2 infants who underwent successful IABP therapy after repair of anomalous left coronary artery. Our experience includes 3 children supported with IABP after repair of anomalous left coronary artery and all 3 survived. Ventricular dysfunction is common both before and after repair of anomalous origin of the left coronary artery and therefore allows for planned insertion. As suggested by Akomea-Agyin, preoperative or intraoperative placement of the IABP for this condition may allow better preservation of cardiac function and coronary flow before the onset of the low output state in the postoperative period.

Intraaortic balloon pumping is valuable to use for some children with acute left ventricular dysfunction. Although the numbers in this series are small, IABP is effective in both medical and postoperative patients and may serve as a bridge to transplant. IABP can be used in nearly all children who meet the indications for treatment. Although no neonates were treated in our series we did treat 3 infants younger than 3 months of age. All of these 3 infants survived. The use of echocardiographic timing in children has been clinically useful in our patients. We recognize the limitations to this study include the retrospective design with a historical cohort. Also the postoperative care of critically ill children has made significant advances during this period and may have a significant effect on survival. The lack of statistical significance for survival in the echocardiographic timed group also may be due to small sample size.

We believe that the use of echocardiography for timing of IABP therapy is helpful in managing pediatric patients with both medical and postoperative indications. Certainly, careful selection of qualified patients is also an important factor. Randomized studies should be performed to identify the safest and most successful therapy for acute left ventricular dysfunction in the pediatric patient.[9]


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 
This article has been selected for the open discussion forum on the CTSNet Web site:http://www.ctsnet.org/doc/5499


   References
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Scheidt S., Wilner G., Muyeller H., et al. Intra-aortic balloon counterpulsation in cardiogenic shock. Report of a cooperative clinical trial. N Engl J Med 1973;288:979-984.
  2. Pollock J., Charlton M.C., Williams W.G., Edmond J., Trusler G.A. Intraaortic balloon pumping in children. Ann Thorac Surg 1980;29:522-528.[Abstract/Free Full Text]
  3. Veasy L.G., Blalock R.C., Orth J.L., Boucek M.M. Intra-aortic balloon pumping in infants and children. Circulation 1983;68:1095-1100.[Abstract/Free Full Text]
  4. Minich L.L., Tani L.Y., McGough E.C., Shaddy R.E., Hawkins J.A. A novel approach to pediatric intraaortic balloon pump timing using M-mode echocardiography. Am J Cardiol 1997;80:367-369.[Medline]
  5. Minich L.L., Tani L.Y., Pantalos G.M., Bolland B.L., Knorr B.K., Hawkins J.A. Neonatal piglet model of intraaortic balloon pumping: improved efficacy using echocardiographic timing. Ann Thorac Surg 1998;66:1527-1532.[Abstract/Free Full Text]
  6. Akomea-Agyin C., Kejriwal N.K., Franks R., Booker P.D., Pozzi M. Intraaortic balloon pumping in children. Ann Thorac Surg 1999;67:1415-1420.[Abstract/Free Full Text]
  7. Webster H.F., Veasy L.G. Intra-aortic balloon pumping in children. Heart Lung J Crit Care 1985;14:548-555.
  8. Veasy L.G., Webster H.F., McGough E.C. Intra-aortic balloon pumping. Adaptation for pediatric use. Crit Care Clin 1986;2:237-249.[Medline]
  9. Torchiana D.F., Hirsch G., Buckley M.J., et al. Intraaortic balloon pumping for cardiac support: trends in practice and outcome, 1968 to 1995. J Thorac Cardiovasc Surg 1997;113:758-769.[Abstract/Free Full Text]
  10. Park J.K., Hsu K.T., Gersony W.M. Intraaortic balloon pump management of refractory congestive heart failure in children. Pediatr Cardiol 1993;14:19-22.[Medline]
  11. del Nido P.J., Swan P.R., Benson L.N., et al. Successful use of intraaortic balloon pumping in a 2-kilogram infant. Ann Thorac Surg 1988;46:574-576.[Abstract/Free Full Text]
  12. Pantalos G.M., Minich L.L., Tani L.Y., McGough E.C., Hawkins J.A. Estimation of timing errors for intraaortic balloon pump use in pediatric patients. ASAIO J 1999;45:166-171.[Medline]
  13. Booker P.D. Intra-aortic balloon pumping in young children. Paediatr Anaesth 1997;7:501-507.[Medline]
  14. Nawa S., Sugawaqra E., Murakami T., Senoo Y., Teramoto S., Morita K. Efficacy of intra-aortic balloon pumping for failing Fontan circulation. Chest 1988;93:599-603.[Abstract/Free Full Text]

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