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Ann Thorac Surg 1997;64:1244
© 1997 The Society of Thoracic Surgeons
DR CARY W. AKINS (Boston, MA): Maybe you can tell us about your techniques of myocardial preservation. One of the issues might be that if your reoperative patients had patent internal mammary grafts that you did not clamp, then the use of counterpulsation would help in perfusing those areas of the myocardium. Tell us about the incidence of arterial grafts that were patent in your redo patients and what your technique of myocardial preservation is.
DR CHRISTENSON: Regarding myocardial preservation, we perform all of our operations using normothermic cardiopulmonary bypass and as myocardial preservation we use cold intermittent cardioplegia infused into the aortic root and local hypothermia with ice slush. Unfortunately, I don't have at hand the number of patent internal mammary artery grafts in this group of patients.
DR ROBERT C. ASHTON (Pittsburgh, PA): Do you do anything to assess either the aortic or peripheral vasculature of these patients before placing the balloon pump, as many of them are at high risk for vasculopathies and can have complications from that?
DR CHRISTENSON: Before we placed the intraaortic balloon pump a standard pulse status measurement of each patient was always performed. If the results were questionable, an ultrasonographic examination or an angiogram was done, if needed, to establish the vascular status. Amazingly enough, though, also routinely using the guidewire of the intraaortic balloon catheter, we did not have any problems in placing any catheter in any of the patients in this series.
DR RONALD M. WEINTRAUB (Boston, MA): One of the problems in the use of the intraaortic balloon pump in patients who are high risk is the difficulty of getting the balloon in when you are coming off bypass. Rather than putting balloons in prophylactically, we have taken the expedient of just passing a wire with a Seldinger technique, passing a 16-gauge long catheter around it, and then if it looks like it's a struggle coming off bypass, it takes less than 5 minutes to put the balloon in even on bypass without a pulsatile artery to feel. I think this technique may save the insertion of unnecessary balloons.
DR CHRISTENSON: I thank you for this comment. I would like to emphasize that in all the patients who received an intraaortic balloon pump catheter preoperatively, we kept the balloon in place during the surgical procedure, and only when we were sure that we could easily get off bypass and we had good hemodynamic stability, the balloon catheter was removed. I believe this is an important point.
DR ELLIS L. JONES (Atlanta, GA): I would like to make one comment. Over the last 5 years, particularly as the age and level of disability of patients have increased—and last year I think 30% of all patients we operated on had diabetes—we have had rather significant problems with peripheral complications in the femoral arteries with the use of intraaortic balloon pumping. We currently do everything we can to avoid using the aortic balloon. I suspect that this has been a trend in the United States, which may not be so common in Europe. But I do know that patients that we are asked to operate on today have a very, very high incidence of peripheral vascular disease, and I shudder to think of using the intraaortic balloon pump routinely on the patients that we are presently seeing. I suspect that this is true of the audience here today.
DR CHRISTENSON: Just to add to that comment, first of all, we are not recommending routine use of IABP in all patients. We have here selected only the high-risk patients.
DR JONES: Reoperative patients.
DR CHRISTENSON: Reoperative patients at high risk. Second, I believe that one crucial thing in this series that diminished the number of balloon complications was to have the balloon in place only for a relatively short period of time. As we use the IABP preoperatively, we have shown that we get off bypass in most of the patients so easily that we can immediately remove the catheter.
Finally, one should choose a relatively small balloon catheter size. I think that there will, in the near future, be some innovative work to construct the introducer part of the catheter smaller so that we do not obstruct the lumen of the artery.
Related Article
Ann. Thorac. Surg. 1997 64: 1237-1244.
This article has been cited by other articles:
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  R. J.F. Baskett, W. A. Ghali, A. Maitland, and G. M. Hirsch The intraaortic balloon pump in cardiac surgery Ann. Thorac. Surg., October 1, 2002; 74(4): 1276 - 1287. [Abstract] [Full Text] [PDF]
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