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Ann Thorac Surg 2005;79:1022
© 2005 The Society of Thoracic Surgeons

New technologyInvited commentary

INVITED COMMENTARY

William L. Holman, MD

Department of Surgery, University of Alabama at Birmingham, 1530 3rd Ave S, Room 719, Birmingham, AL 35294-0007

(E-mail: wholman{at}its.uab.edu).

This article describes a novel algorithm to predict the dicrotic notch for timing intraaortic balloon pump (IABP) counterpulsation. The algorithm uses pressure readings from a high fidelity fiberoptic micromanometer embedded in the tip of the IABP. This system was evaluated in 27 patients with low ejection fractions who were undergoing cardiac operations. Balloon inflation and deflation were accurate in the vast majority of arrhythmic beats. Pressure-volume data were shown that suggests this technology will provide better support than conventionally timed IABP counterpulsation.

Since the initial use of IABP counterpulsation, attempts have been made to improve the timing of balloon inflation and deflation, particularly in patients with arrhythmias. The present attempt at such a system appears to provide good results, at least in a limited number of patients, but obstacles remain. One potential problem with using pressure data from transducers embedded in the tip of the IABP is artifact. The system is essentially a refined pulse pressure-based sensing algorithm that derives flow from high fidelity pressure measurements. Thus the system is vulnerable to timing errors due to artifacts in the pressure data. This was not encountered in the study, but it can occur even with readings from a fiberoptic micromanometer. Another potential problem is a malignant arrhythmia that generates pulse pressures below the threshold for detection. These are arguably the most dangerous arrhythmias to a patient. What are the limits for pulse pressure and first derivative of pressure relative to time (dP/dt) below which the system becomes inaccurate? A third issue is the rate limit of the system. It is presumably the same as the limit for IABPs that use conventional electrocardiogram or pressure triggers. Ultimately, the problem with effective IABP counterpulsation during a tachyarrhythmia becomes shuttling helium back and forth in the IABP and not tracking the dicrotic notch.

The final question relates to cost and indications for use. Catheters with embedded micromanometers cost more than conventional IABP catheters, but an outcome benefit for this novel IABP timing system has not yet been demonstrated. Determining the benefit in terms of survival, morbidity, and duration of hospitalization will be crucial for defining the role of this technology in clinical practice.


Related Article

Automatic Intraaortic Balloon Pump Timing Using an Intrabeat Dicrotic Notch Prediction Algorithm
Jan J. Schreuder, Alessandro Castiglioni, Andrea Donelli, Francesco Maisano, Jos R.C. Jansen, Ramzi Hanania, Pat Hanlon, Jan Bovelander, and Ottavio Alfieri
Ann. Thorac. Surg. 2005 79: 1017-1022. [Abstract] [Full Text] [PDF]




This Article
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