Intraaortic Balloon Assist Through Cannulation of the Ascending Aorta Terry L. Gueldner, M.D., a n d G. H. Lawrence, M.D. ABSTRACT This report describes a survivor and the technique of intraaortic balloon assistance through cannulation of the ascending aorta. Other sites of balloon insertion and their complications are briefly discussed. The thoracic aorta route for balloon assistance has proved effective and may well be preferable when significant aortoiliac disease exists.

I

n many of the major cardiac surgery centers, intraaortic balloon assistance (IABA) has become an accepted means of dealing with cardiac failure following acute myocardial infarction or cardiopulmonary bypass [ 1-3, 51. T h e usual means of inserting the balloon is through either common femoral artery within a prosthetic graft, thereby allowing perfusion of the distal extremities [4, 6, 81. With its increasing use in various age groups, one not infrequently encounters patients with significant aortoiliac disease in whom successful insertion of the balloon into the descending aorta is difficult [2, 3, 81. This report describes a patient who required cannulation of the ascending aorta for balloon insertion following cardiopulmonary bypass; the balloon was removed some 24 hours after cardiovascular stabilization. This 64-year-old white woman had mild adult-onset diabetes mellitus, rheumatic heart disease with severe mitral regurgitation, mild compensated congestive heart failure, and coronary artery disease with angina pectoris, N.Y.H.A. Class I11 to IV. Angiography revealed nearly total occlusion of the proximal right coronary artery and only minimal irregularities in the anterior descending coronary artery and circumflex vessels. There was calcification of the mitral annulus and leaflets with marked mitral regurgitation, good left ventricular contractility, and no evidence of aortic regurgitation. Catheterization data were as follows: cardiac output, 3.653 L/min; cardiac index, 2.56 L/min/m2; total pulmonary resistance, 525 dynes sec cm"; pulmonary vascular resistance, 197 dynes sec cm-6; mean right atrial pressure, 6 mm Hg; mean pulmonary artery pressure, 24 mm Hg; mean pulmonary capillary wedge pressure, 15 mm Hg; mean left ventricular pressure, 130/0-19 mm Hg. Operation was begun through a median sternotomy incision, and the From the Department of Surgery, Cardiothoracic Section, The Mason Clinic, Seattle, Wash. Accepted for publication July 23, 1974. Address reprint requests to Dr. Lawrence, 1118 Ninth Ave., Seattle, Wash. 98101.

88

THE ANNALS OF THORACIC SURGERY

CASE REPORT:

ZABA through Aortic Cannulation

patient underwent uneventful mitral valve replacement with a Bjork-Shiley valve and saphenous vein bypass of the right coronary artery occlusion. T h e heart was cooled with iced saline and slush during the procedure. Pump perfusion through the right femoral artery was satisfactory, without obstruction to flow. T h e patient came off bypass slowly with poor cardiac output and arrhythmias; after her condition was stabilized with mild vasopressor support, the sternotomy incision was closed. Prior to leaving the operating room she became hypotensive and unresponsive to increased vasopressor support. T h e sternum was immediately reopened, and she was placed on emergency cardiopulmonary bypass with aortic arch cannulation. She was unable to be weaned from the pump, and intraaortic balloon assistance was deemed essential. Attempts at passing various sizes of balloon" into the descending aorta from either femoral artery or the right iliac artery were impossible because of significant aortoiliac occlusive disease. It was necessary to insert the balloon through the ascending aorta just distal to the saphenous vein aortotomy and aortic arch perfusion cannula. The device was secured with Tevdek pursestring sutures and Teflon pledgets (Figure). With the intraaortic assistance her cardiac output and pressures were well maintained off cardiopulmonary bypass. She could not be weaned from the IABA, however, and it was necessary to close the sternum with the balloon in place, bringing the cannula out through the lower portion of the midline incision. With the IABA the patient's systolic pressure was maintained in a satisfactory range over the next 26 hours (Table), and she tolerated weaning from the 1: 1 assist. T h e patient was then taken back to the operating room for balloon removal, at which time she spontaneously fibrillated, requiring reinstitution of the IABA. At open thoracotomy it was evident that she had suffered a perioperative infarction. Following intravenous administration of Levophed her pressures soon stabilized with no further arrhythmias, and she was successfully weaned from the balloon assist. T h e device was removed and the sternum closed. During the next 48 hours she required mild Levophed pressor support. Despite continuous administration of lidocaine, she required defibrillation during the first 24 hours postoperatively from two episodes of ventricular fibrillation. On the fourth postoperative day her endotracheal tube was removed, and she was given digitalis for atrial fibrillation. Pronestyl was started on the fifth postoperative day, and the lidocaine drip was discontinued on the sixth day. Her perioperative infarction as visualized at time of balloon removal was confirmed by the postoperative ECG, a creatine phosphokinase (CPK) value of 1,475 I.U./liter, and the presence of CPK isoenzyme. She was discharged home on the seventeenth postoperative day, at which time she was doing quite satisfactorily. This patient is the eighth survivor of IABA at the Virginia Mason Hospital [GI. *Datascope Corp., Saddle Brook, N.J.

VOL.

19, NO.

1, JANUARY,

1975

89

GUELDNER AND LAWRENCE

Zntraaortic balloon inserted through the ascending aorta utilizing two encircling sutures of Teflon-coated Dacron reinforced with Teflon felt.

Comment The femoral artery is perhaps the most practical site for balloon insertion since exposure is readily obtained at the bedside under local anesthesia or during the primary cardiopulmonary bypass procedure. Unfortunately, arteriosclerosis of the femoral, iliac, and distal aorta compromises the lumen of the vessel and may lead to various complications when using IABA. These include inability to pass the balloon with subsequent death from cardiogenic failure, thrombosis and ischemia of the extremity with subsequent amputation, and major vessel perforation and hemorrhage [Z,3, 8, 91. Bregman, Bolooki, and Malm [4] have suggested bending the flexible wire in the proximal dual-chambered balloon to facilitate the negotiation of tortuous arteriosclerotic junctures. Saini and Berger [8], however, caution against forcible passage of the catheter or overmanipulation for fear of undermining a plaque and causing subsequent perforation. Upper extremity and axillary arteriotomy for balloon insertion has not proved entirely satisfactory [8]. Transabdominal balloon insertion into the aorta has not, to our knowledge, been reported in the literature. Inherent complications with this approach might be related both to the extensive abdominal and retroperitoneal dissection with prolonged postoperative ileus and to plaque dislodgement from the diseased abdominal aorta. Although

90

THE ANNALS OF THORACIC SURGERY

CASE REPOUT:

ZABA through Aortic Cannulation

BLOOD PRESSURES, URlNE OUTPUT, AND DRUGS ADMINISTERED DURING 26 HOURS OF IABA

Pressure in Radial Artery Time (mm Hg) Before operation 130/80 Before IABA 80/30 lV2 hr (1:l assist) 120/50 12 hr (1:l assist) 120/00 16 hr (IABA 130/00 wean) 26 hr (IABA out) 115/00

CVP (cm H,O)

LAP (cm H,O)

Urine Output (ml/hr)

14 7 11 13

19

... ...

200 130 70 120

47 None None

3

None None 1 1

...

40

1

2

... 12

...

. . .a

...

Drugs Administered Levophed Xylocaine (,ug/min) (mg/min)

...

...

~~

"Left atrial line removed during return to emergency cardiopulmonary bypass. CVP = ccntral venous pressure; LAP =left atrial pressure; IABA = intraaortic balloon assist.

transthoracic balloon insertion means subsequent thoracotomy for removal, this technique may prove lifesaving in selected patients.

References 1. Berger, R. L., Saini, V. K., Ryan, T. J., Sokol, D. M., and Keefe, J. F. Intraaortic balloon for post cardiotomy cardiogenic shock. J Thorac Cardiouasc Surg 66:906, 1973. 2. Bregman, D., and Goetz, R. H. Clinical experience with a new cardiac assist device. J Thorac Cardiouasc Surg 62:577, 1971. 3. Bregman, D., Kripke, D. C., Cohen, M. N., Laniado, S., and Goetz, R. H. Clinical experience with the unidirectional dual-chambered intra-aortic balloon assist. Circulation 43, 44 (Suppl I):82, 1971. 4. Bregman, D., Bolooki, H., and Malm, J. R. A simple method to facilitate difficult intra-aortic balloon insertions. Ann Thorac Surg 15:636, 1973. 5. Buckley, M. J., Craven, J. M., Gold, H. K., Mundth, E. D., Daggett, W. M., and Austen, W. G. Intraaortic pump assist for cardiogenic assist after cardiopulmonary bypass. Circulation 46 (Suppl II):76, 1973. 6. Kantrowitz, A., Phillips, S. J., Butner, A. N., Tjgnneland, S., and Haller, J. D. Technique of femoral artery cannulation for phase-shift balloon pumping. J Thorac Cardiouasc Surg 56:219, 1968. 7. Lawrence, G. H. Intra-aortic balloon counterpulsation for the treatment and prevention of cardiogenic shock. A m J Surg 128: 188, 1974. 8. Saini, V. K., and Berger, R. L. Technique of aortic catheter deployment with the use of a Fogarty catheter. Ann Thorac Surg 14:440, 1972. 9. Scheidt, S., Wilner, G., Mueller, H., Summers, D., Lesch, M., Wolff, G., Krakauer, J., Rubenfire, M., Fleming, P., Noon, G., Oldham, H., Killip, T., and Kantrowitz, A. Intra-aortic balloon counterpulsation in cardiogenic shock. N Engl J Med 288:979, 1973.