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Ann Thorac Surg 2002;74:751-752
© 2002 The Society of Thoracic Surgeons
a Surgical Director of Cardiac Transplantation and, Mechanical Assistance Program, Newark Beth Israel Medical Center, 201 Lyons Ave at Osborne Terrace, G5 Newark, NJ, USA 07112
e-mail: dgoldstein{at}sbhcs.com
The authors from the University of Wisconsin present their small experience with the use of balloon counterpulsation in an ambulatory fashion (AIABP) as a bridge to transplantation. The recipients of this modality of support suffered from ischemic pathologies and had relative contraindications to the institution of more sophisticated mechanical support.
As with all medical technologies and surgical endeavors, success is largely contingent upon patient selection; hence, the limitations of balloon support must be underscored. Balloon counterpulsation improves cardiac output in the order of 10% to 15%, does not displace volume, and cannot be considered a true "assist device." Desperately ill patients requiring left ventricular replacement, would not benefit sufficiently from this mode of support. For patients with significant arrhythmias or those with normal coronaries, balloon counterpulsation may not be effective. Finally, institution of IABP support in patients with significant atherosclerotic disease of the left subclavian system and/or descending aorta could prove disastrous.
The idea and technique of ambulatory balloon support, though not new, has been successfully modified and expanded by the authors to serve as a bridge to transplantation. Several advantages of this approach should be highlighted. First, and perhaps most attractive, is that a trial of effectiveness with conventional balloon support can be undertaken. Second, the modified technique reduces the chance of driveline kinking, permits normal ambulation, and allows easy access for balloon exchange(s) if necessary. One should not disregard the physical and psychological benefits derived from avoidance of the bedridden state in the hospital setting. Third, presence of an IABP at the time of transplantation does not complicate native heart excision and, in fact, can aid in separation from cardiopulmonary bypass in the event of right ventricular dysfunction. Last, compared to current mechanical support systems, the AIABP represents a relatively inexpensive alternative.
The contraindications that led the authors to pursue AIABP support included ascites (presumably right heart failure related), advanced transplant vasculopathy, and small body size. At present, these contraindications can be addressed by more sophisticated (albeit more expensive, invasive, and less ubiquitous) systems like the biventricular Thoratec system and the second generation axial flow pumps (e.g., Micromed-DeBakey VAD, Jarvik 2000). It is of interest that the AIABP concept has been carried one step further by the CardioVAD system, an implantable counterpulsation support system designed for outpatient support, currently in clinical trials.
The authors’ success convincingly argues for a "test drive" of conventional balloon support in transplant candidates with ischemic pathologies and moderate hemodynamic decompensation. Should this prove beneficial, institution of ambulatory balloon counterpulsation therapy can be strongly considered. The implications regarding cost containment and salvage of heart transplant candidates admitted to a nontransplant center, where IABP is the only modality of support available, are potentially of great significance.
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