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Ann Thorac Surg 2002;74:1276-1287
© 2002 The Society of Thoracic Surgeons

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Review

The intraaortic balloon pump in cardiac surgery

^a The Maritime Heart Centre, Dalhousie University, Halifax, Nova Scotia, Canada
^b Department of Medicine, University of Calgary, Calgary, Alberta, Canada
^c Department of Surgery, University of Calgary, Calgary, Alberta, Canada

* Address reprint requests to Dr Baskett, Maritime Heart Centre, Room 2269, 2nd Floor, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
e-mail: rogerbaskett{at}hotmail.com

	Abstract

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
The intraaortic balloon pump (IABP) has been used in cardiac operations since the late 1960s. Over the years, with refinements in technology, its use has expanded; the IABP is now the most commonly used mechanical assist device in cardiac operative procedures. This review provides an evaluation of evidence for the efficacy of IABP use in different clinical scenarios, using the American College of Cardiology/American Heart Association classification of evidence where appropriate. We evaluated complications and outcomes associated with IABP use, and attempted to draw conclusions regarding the use of the IABP in different clinical situations. We examined the trends and variation in utilization over time and across centers. We discussed the IABP in light of new cardiac assist devices and the changing patient population and management strategies. Lastly, we identified areas of future research.

	Introduction

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Results of cardiac operative procedures continue to improve despite ever-increasing numbers of older and sicker patients [1]. Of those who die, many do so of complications relating to low cardiac output during the perioperative period. The intraaortic balloon pump (IABP) has been widely used during the perioperative period to support patients with low cardiac output. The IABP was first used clinically in 1968 for supporting patients with cardiogenic shock after acute myocardial infarction [2]. Soon its use was expanded to postoperative support and as an aid in weaning patients from cardiopulmonary bypass [3, 4]. Use of the IABP has continued to increase, particularly over the past decade with the expansion of interventional cardiology, and the increasing age and acuity of cardiac surgical patients (Table 1) [5–8].

	Method of review

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
A search of the MEDLINE database from 1966 to 2000 was undertaken using the keyword intraaortic balloon pumping, limited to human studies published in English. We excluded articles that were abstracts only, involved nonsurgical patients only, did not satisfactorily distinguish between surgical and nonsurgical patients, or included fewer than 30 patients. Additional references were obtained by direct communication with experts in the field. Manuscripts cited in the references retrieved were also reviewed. Studies’ designs were documented as an indicator of the strength of evidence they represented. Where appropriate, evidence was classified and graded using the American College of Cardiology/American Heart Association guidelines [11]:

Class I: Conditions for which there is evidence for or general agreement that the procedure or treatment is useful and effective;

Class II: Conditions for which there is conflicting evidence or a divergence of opinion about the usefulness/efficacy of a procedure or treatment;

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy;

Class IIb: Usefulness/efficacy is less well established by evidence/opinion;

Class III: Conditions for which there is evidence or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful.

Levels of evidence were graded as follows: Level A = data derived from multiple randomized clinical trials; level B = data derived from single randomized trial or nonrandomized studies; and level C = case series or consensus opinion of experts.

	Indications

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
The IABP exerts its effect by volume displacement. It has two principal effects; the first is to augment coronary blood flow, and thus myocardial oxygen supply, by increasing diastolic perfusion pressure. The blood displaced during balloon inflation reduces ventricular work by reducing afterload with rapid balloon deflation in systole, thus decreasing myocardial oxygen consumption [9]. This action enhances stroke volume and in conjunction with the favorable diastolic effects can increase cardiac output by 20% [10].

The currently accepted indications for IABP use have expanded to include [12]:

1. Ongoing unstable angina refractory to medical therapy
   
2. Acute myocardial ischemia/infarction associated with percutaneous transluminal angioplasty (PTCA)
   
3. Perioperative low cardiac output syndrome
   
4. Cardiogenic shock after myocardial infarction
   
5. Congestive heart failure
   
6. Bridge to heart transplant
   
7. Ischemic ventricular septal defect
   
8. Acute mitral valve insufficiency
   
9. Poorly controlled perioperative ventricular arrhythmias.
   

Although most surgeons accept many of these indications, the decision to use an IABP and the timing of its use are often not clear. No direct multicentered comparisons of use or outcomes with the IABP have been published, thus direct comparison is difficult due to the heterogeneity of patient populations and changes in practice patterns over time [13]. Intraaortic balloon pump use has shifted more toward ischemia rather than hemodynamic decompensation [6, 14, 15]. This change is likely the result of steady improvements in surgical and anesthetic techniques over this period, which have reduced the need for IABPs for early postoperative low cardiac output [8].

	Evidence for efficacy of preoperative intraaortic balloon pump use

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Case series
A number of case series found that preoperative insertion of an IABP was associated with better outcomes than intra- or postoperative insertion [6, 15, 16]. In the mid-1970s, preoperative balloon pump use was found to be beneficial in high-risk surgical patients [17–20]. However its use remains highly variable and there is a lack of consensus for preoperative use, when the decision is most discretionary [13, 21–23].

Nearly all published studies have demonstrated that patients receiving IABPs preoperatively have better outcomes than those receiving IABPs intraoperatively or postoperatively (Table 1). This finding is a reflection of the fact that the IABPs are being inserted for different indications. Even in series reported in the 1970s and early 1980s, preoperative IABP use was associated with a 74% to 90% survival [24, 25]. The few series that reported poor survival with preoperative IABP use only rarely used the device preoperatively, and used it principally for shock [26, 27].

Observational studies with controls
We identified a total of six controlled observational studies of preoperative IABP use (Table 2). Feola and associates [28] reported in a small series of patients with low ejection fractions undergoing isolated coronary artery bypass grafting (CABG), that those receiving preoperative IABP support had significantly lower myocardial infarction rates and mortality compared with matched historical controls (Table 2). More recent reviews have also suggested the potential beneficial effects of preoperative IABP use, but have failed to consistently show a statistically significant difference in comparison with similar untreated patients [29, 30]. In a cohort of postmyocardial infarction patients undergoing CABG, Creswell and associates [30] demonstrated encouraging trends toward decreased mortality and morbidity in patients with preoperative IABP use operated on less than 14 days after acute myocardial infarction (Table 2). A cohort study by Dietl and associates [7] suggested a survival benefit with preoperative use of the IABP in patients with an ejection fraction of less than 0.25 (Table 2). In addition, they identified several predictors of the need for intra- and postoperative IABP support in these patients: reoperation, unstable angina, use of intravenous nitroglycerin, left main stenosis, acute myocardial infarction within 7 days, nonelective operation, and New York Heart Association class III–IV symptoms. These findings suggest that CABG patients with ejection fractions of less than 0.25 and one or more of these factors represent the subset of CABG patients who should be selected for preoperative IABP use.

Gutfinger and associates [32] examined a series of patients older than 70 years of age undergoing isolated CABG and having one of the following: left main stenosis 70%, medically refractory unstable angina, ejection fraction 0.40, failed PTCA, or reoperation (Table 2). Compared with a concurrent group of similarly aged patients, those receiving the preoperative IABP had significantly higher Parsonnet scores, lower ejection fractions, and twice the incidence of congestive heart failure and acute myocardial infarction. The 30-day crude mortality was not statistically significantly different (Table 2).

Randomized controlled trials
Recently, a series of reports by Christenson and associates [34–37] from Geneva described results of what appear to be subgroups of two prospective randomized controlled trials (conducted in a single institution). These reports concluded that preoperative IABP insertion in high-risk CABG patients decreased mortality and postoperative length of stay (Table 3) [5, 34–36]. High risk was defined as any two of the following: medically refractory unstable angina, ejection fraction 0.40, left main stenosis 70%, or redo surgery. Overall, 11 of 50 control patients died compared with 3 deaths among 62 receiving the IABP preoperatively (p = 0.007) [37].

Summary of evidence for preoperative intraaortic balloon pump use
The optimal use of the IABP in cardiac operations remains controversial, and poorly defined [25, 31]. Some of the controversy concerns the definition of a high-risk patient [38]. In some centers, fear over cost and complications of the IABP constrains use [39]. Others claim that preoperative IABP use in most patients is not necessary and that a femoral line could be inserted in the operating room to facilitate balloon introduction only if difficulties arise in weaning the patient from bypass [40]. However, much of the benefit derived from preoperative insertion and use of the IABP may be the result of improved myocardial perfusion and stability in the induction of anesthesia and the early operative period before commencing bypass [5, 32]. The difficulty lies in being able to identify those patients who are at risk of perioperative decompensation and thus would benefit most from a prophylactic IABP [31, 32].

In conclusion, there is class I level B evidence that preoperative IABP use in ischemic CABG patients is beneficial. There is class I level B evidence for preoperative IABP use in CABG patients with ejection fraction less than 0.25 who are undergoing nonelective operation or reoperation, or who have New York Heart Association class III–IV symptoms [7]. The evidence is less clear for those patients without ongoing ischemia, but who (in isolation) are undergoing reoperation, have low ejection fraction, have left main disease in isolation, or are undergoing procedures other than isolated CABG. There is class IIa level B evidence for preoperative IABP use in these patients.

	Evidence for efficacy of intraoperative and postoperative intraaortic balloon pump use

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Overall mortality in patients receiving IABPs intra- and postoperatively ranges from 21% to 73% (Table 1) [30, 41]. Patients receiving IABPs intra- and postoperatively differ from those receiving the device preoperatively. They may have been considered lower risk or were more stable preoperatively IABP than those receiving a preoperative IABP. The outcome of these patients may have been have been worse without the support of the IABP. Both intra- and postoperative IABP insertion and cardiogenic shock have been identified as independent predictors of mortality [6, 29, 42].

Intraaortic balloon pump use for weaning from cardiopulmonary bypass is well established, although the specific indications and the threshold for use are hard to analyze. Survival of patients requiring intraoperative IABP support is usually reported to be more than 50% (Table 1) [22, 43]. These patients likely would not have been separated from bypass without IABP assistance and would have died. However in a large series, 40% of the patients receiving an IABP intraoperatively ultimately required a ventricular assist device [44].

Intraoperative and postoperative IABP insertion is an indication of serious complications, which are often not correctable. As such, these patients face a high mortality. An IABP inserted for low cardiac output rather than ischemia is clearly associated with a poorer prognosis [6, 22, 43]. Not surprisingly, patients requiring intraoperative or postoperative IABP insertion have mortalities similar to those patients receiving an IABP for medical treatment of postmyocardial infarction shock [43, 45]. In addition the effect of the IABP on flow in bypass grafts is unclear and seems to be related at least in part to the graft used and its proximal origin [46, 47]. Thus in some cases IABP use may be of uncertain benefit [48].

Only one study [13] has reported outcomes of patients receiving intra- or postoperative IABP compared with any similar risk group. In a series of 319 patients, 280 received an IABP and 39 "controls" had failed attempts at balloon insertion [13]. Only 17 of the balloons were used preoperatively. In these similar risk groups a trend was noted toward decreased overall operative death, along with a significant benefit in those undergoing isolated CABG (33% vs 64% p = 0.03).

In conclusion, IABP use for weaning from bypass is well established although the evidence is hard to produce. There is class I level C evidence for the use of the IABP for weaning from bypass in CABG patients. There is class IIa level C evidence for postoperative IABP use in CABG patients. An important related issue that needs to be addressed is the appropriate use of a ventricular assist device in this setting.

	Evidence for efficacy of intraaortic balloon pump use in cardiac operations other than isolated coronary artery bypass grafting

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
The type of operation and the timing of balloon pump use is a major determinant of survival [49]. The superior

	Evidence for efficacy of intraaortic balloon pump use in cardiac operations other than isolated coronary artery bypass grafting

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
The type of operation and the timing of balloon pump use is a major determinant of survival [49]. The superior in-hospital and long-term survival of isolated CABG patients receiving IABPs, compared with patients undergoing other types of cardiac operative procedures, has been confirmed by many studies [15, 16, 27, 43, 50]. In a large series of IABP cases reported from Boston, Torchiana and coworkers [6] demonstrated that a procedure other than CABG was associated with a twofold increased risk of death. They also identified cardiogenic shock, heart failure, and mitral valve replacement as being independently associated with mortality. It is clear that patients with ongoing ischemia associated with shock do much better than those with shock and no ischemia [45]. In fact the superior survival in isolated CABG compared with valvular and other combined procedures persists regardless of timing of insertion [15]. No studies were identified in which non-CABG patients with and without an IABP were compared.

The higher mortality of patients with valvular disease and cardiogenic shock who receive an IABP is a reflection of the fact that the problem of ventricular dysfunction is either not reversible or only partially so. The IABP can improve cardiac output by only 10% to 20%, and thus is inadequate in cases requiring large doses of inotropic agents [10, 29]. Patients with profound hemodynamic compromise persisting after IABP insertion will likely survive only with a ventricular assist device [6, 51].

There is insufficient evidence to grade the use of the IABP in patients undergoing procedures other than isolated CABG.

	Other considerations

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Long-term outcomes
It is recognized that the presence of an IABP defines a very high-risk group of patients [52]. Depending on the proportion of IABPs used preoperatively, 5-year survival is reported to be between 22% and 47% [15, 29, 53, 54]. Downing and associates [13] reported that 2-year actuarial survival was superior in those who received an IABP (45%) compared with those who did not (23%, p = 0.006). The best results appeared to be in transplant recipients (81%) and those undergoing isolated CABG (51%), whereas CABG with aortic valve replacement had the lowest actuarial survival of 34% at 5 years [15, 45].

A recent long-term study of 163 IABP patients who survived to hospital discharge demonstrated that those surviving to discharge have good long-term survival, comparable to that of patients with similar risk [16]. In a study of prophylactic IABP use in isolated CABG patients, no difference was found in hospital and early mortality [31]. At 3 years, however, a trend was noted toward better survival in the group receiving prophylactic IABPs [31].

In conclusion, IABP patients who survive to discharge appear to have good survival, which is determined by their disease and comorbidities. There is class IIb level B evidence that IABP use in CABG patients improves long-term survival.

Cost of intraaortic balloon pump use
In addition to a significant decrease in mortality and postoperative length of stay, Christenson and associates [37] reported that preoperative IABP use was associated with lower costs of in-hospital care and a shorter length of stay. They reported similar results in reoperative patients [5].

Dietl and associates [7] also reported a reduced length of stay with preoperative IABP use (10 vs 12 days). Mean hospital costs were also reduced by USD$4,000 per patient [7]. Using administrative data, Holman and associates [31] reported a decreased length of stay of 1 day in patients receiving prophylactic preoperative IABP compared with matched patients.

In conclusion, patients requiring IABPs by their nature are at high risk and thus will have longer hospital stays and spend more time in the intensive care unit. It appears that use of an IABP is unlikely to increase cost, and there is class I grade B evidence that preoperative insertion in selected CABG patients will decrease overall costs [31].

	Complications of intraaortic balloon pump use

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
The use of IABPs is not without complications, which occur in 11% to 33% of cases (Table 4) [14, 55]. This range is largely a reflection of varied definitions of complications. The overall and ischemic complication rates do not appear to have changed substantially over time (Table 4). In a recent prospective study of 1,119 consecutive patients receiving IABPs, Cohen and associates [56] reported an overall complication rate of 15% with 46 patients requiring operation for their complications and only 5 deaths directly attributable to the use of an IABP.

Long-term follow-up of patients with lower limb ischemia as a result of IABP use revealed that 18% of patients had signs and symptoms of chronic limb ischemia [61]. Multivariate predictors of chronic ischemia include acute limb ischemia, cardiogenic shock, and smoking. This high rate of chronic ischemia has resulted in reluctance, on the part of some surgeons, to use the IABP [5, 39, 62, 63].

A number of investigators have examined risk factors for IABP-related vascular complications. Female sex, history of peripheral vascular disease, and diabetes have been consistently identified as independent risk factors for vascular complications [55, 56, 58, 59, 65–67]. Others have implicated duration of IABP use, smoking, and hypertension as risk factors [14, 68–71].

Aortic or iliac dissection or perforation are rare but usually fatal complications of IABP insertion, occurring in about 1% of cases (Table 4). If autopsy cases are included, the incidence of this complication can be has high as 5% to 9% [55]. Death as a direct result of IABP use is hard to quantify, except in the cases of dissection and perforation, but is reported to occur in 0.5% to 4% of cases [65, 72].

Other complications
Other complications include bleeding, infection [55, 73], stroke, and other embolic complications including paraplegia [74, 75]; neuropathy and chronic pain occur less frequently (Table 4). Entrapment of the IABP has been reported only rarely and appears to be associated with balloon rupture and subsequent clot formation within the balloon [75, 76]. Some surgeons think that the benefits of prophylactic IABP use do not outweigh the risk of complications, and that use of the IABP should be restricted to life-threatening conditions only [64].

Insertion technique
In 1980, percutaneous IABP insertion came into common usage. A number of studies have suggested that the percutaneous method has a higher complication rate than traditional surgical exposure of the femoral vessels and insertion under direct vision [55, 59, 77, 78]. A prospective, randomized controlled trial of 101 patients found that although percutaneous insertion was faster and technically easier, it was associated with a significantly higher vascular complication rate (11/51 vs 2/50 p < 0.05 [79]. Despite the related complications, percutaneous insertion has become the standard first method of insertion in most centers. This is partly because of the changing nature of use (now used more frequently by cardiologists than surgeons) [6] and the recognition that the differences in complications are partly due to physician experience with the technique [79]. In addition, percutaneous insertion avoids the mandatory need for reoperation to remove the IABP.

Alternative routes of intraaortic balloon pump insertion
Alternate routes of IABP insertion can be used when occlusive aortoiliac disease or prior abdominal aortic or femoral artery operation prevents femoral artery insertion [80]. Insertion of the IABP through the ascending aorta, iliac, subclavian, and axillary arteries have all been reported [81–84].

Of these methods, transthoracic arch insertion is the most frequently used and has been reported in 1.9% to 6.2% of all IABP procedures [6, 29]. Transthoracic arch insertion of IABPs occurs intra- or postoperatively in patients in whom femoral insertion had failed; the mortality is similar to that reported overall for intra- and postoperative use in larger series (25% to 73%) [15, 22, 80, 85] (Table 1). Pinkard and associates [86] found in analyzing a series of 123 IABPs inserted for weaning from bypass in CABG patients (42 transthoracic and 81 femoral) that the increased mortality in the arch insertion group was a result of the greater comorbidities rather than the route of insertion. Additionally, no increase in complications was noted in the aortic insertion group, whereas the patients with femoral insertion had a higher incidence of leg complications. The largest reported series of transthoracic IABP insertion (n = 100) also demonstrated no increased mortality and complication rates similar to those of femoral insertion [85].

There is Class I level C evidence and general agreement that arch insertion is a good second choice if femoral insertion is not possible [80, 85, 86].

	Intraaortic balloon pump use

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Overall use of the IABP in cardiac surgical patients varies from 1.5% to 17% of all cases (Table 1) [6, 26]. This marked variation in use remains high even after risk adjustment (7.8% to 20.8% of cases), indicating that in many centers the IABP is being either over- or underused [41]. Optimal use of the IABP in cardiac operation has not been clearly defined.

Over time, from the early 1970s through to the 1990s, the trend has been toward increased use (Table 1). In the largest published single-center experience with the IABP (The Massachusetts General Hospital), increasing usage has been associated with increasing risk of the patient population, and the introduction of the percutaneous method of insertion, which has broadened the availability and feasibility of balloon pump use [6, 79]. In addition, increased use of the IABP for ischemia rather than hemodynamic instability has contributed to the increased use [6, 15].

Use of the IABP in the preoperative period has also increased in many centers. This change is partly in response to recognition of the superior results of the IABP in ischemic patients [6, 8, 15, 29]. However, the variation between centers within the same time periods is substantial (Table 1). The proportion of IABPs used preoperatively ranges from 0% to 74% (Table 1) [19, 87]. Even recent series report the use of preoperative IABPs in only a minority of cases, as low as 4% to 12% of all IABPs [50, 60]. This wide variation reflects a lack of consensus over specific indications and a lack of widely accepted guidelines; in many respects the variation also represents differing philosophies of management [15, 88].

In summary, use of the IABP in cardiac operations appears to be center specific and inconsistent across centers.

	Intraaortic balloon pump use in children

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Use of the IABP in children has been limited, partly because of technical difficulties, although appropriate equipment has been developed [89–93]. Physiologic differences including greater compliance of the pediatric aorta, the large bronchial vessel in cyanotic diseases, and the higher heart rates in children, make augmentation difficult to achieve [91, 93]. Most importantly, children with congenital heart disease are more likely to have isolated right ventricular failure, biventricular failure, or pulmonary hypertension, which would require the use of extracorporeal membrane oxygenation or a ventricular assist device [89, 93].

Reported survival with IABP use in children ranges from 25% to 66%, but the largest series reported is only 29 patients [90, 94, 95]. These results are similar to those in adults receiving intra- or postoperative IABP support (Table 1). Results of extracorporeal membrane oxygenation support in children (61% to 71% survival) are better than IABP [96, 97]. Intraaortic balloon pumps appear to be most effective in older children, in whom augmentation is more reliably achieved [90, 91], and specifically in those with isolated left ventricular failure, such as those with anomalous coronary artery repairs, myocarditis, or Kawasaki’s disease, or as a bridge to transplantation [92, 93, 95, 98]. There is class IIa grade C evidence for IABP use in hemodynamically unstable children.

	Trends

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Evidence suggests that the IABP can also be used to support primarily right ventricular failure, particular in the transplant population [99]. The IABP has also been found to be an effective adjuvant to off-pump CABG [100, 101]. Longer-term IABP use has been effectively used as a bridge to transplant, although its role in the era of long-term safe ventricular assist devices may be more limited [70]. Use of the balloon pump has been extended with good results to the increasing population of elderly [32, 102, 103].

Over the past 5 years, use of preoperative IABPs has increased in some centers [5, 6]. This increase has been associated with a decrease in mortality. It remains difficult to identify those patients who will benefit most from the IABP, while minimizing the device-related complications. The trend has been toward prophylactic use to avoid rather than treat ischemia [5, 31]. Use of preoperative IABPs will probably continue to increase as the criteria for use are better defined, and the population of patients presenting for cardiac operations becomes older and higher risk. Use of the IABP in high-risk angioplasty and primary angioplasty for acute myocardial infarction will also likely increase, as will its use for off-pump operations. Smaller catheter sizes will likely further reduce, although not eliminate, the incidence of vascular complications.

	Future research

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
Despite more than 30 years of clinical use and the large body of literature on IABPs, several critical questions remain to be answered. Appropriate and optimal use of the IABP, particularly preoperatively, remains to be clarified. The provocative results of a small but limited randomized controlled trial showing a survival benefit with the use of preoperative balloon support in high-risk cases needs to be validated, perhaps with a large series of observational data, and multi-institution comparisons. The role of the IABP for intraoperative and postoperative support relative to the use of ventricular assist devices needs to be defined, probably in the setting of a multicentered trial.

	Selected references*

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
[33]

	Footnotes

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 
^* The reference section of the print version of this article contains 80 selected references, the numbers of which correspond to their text citation numbers. The complete list of all 115 references is viewable at: http://ats.ctsnetjournals.org.

	References

Top Abstract Introduction Method of review Indications Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Evidence for efficacy of... Other considerations Complications of intraaortic... Intraaortic balloon pump use Intraaortic balloon pump use... Trends Future research Selected references* Footnotes References

 

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