Intra-aortic balloon pump is the most commonly
used device which is easy to access, easy to implement,
inexpensive, and still the most widely used device
which increases myocardial supply and demand
balance, by improving myocardial performance.[
5]
However, several complications may be seen due to its widespread use. These complications include
vascular complications, balloon-related complications,
and infections. Vascular complications include lower
extremity ischemia, peripheral thrombosis and
embolism, vasospasm which may result from local
vascular damage during insertion of the catheter,
hematoma, pseudoaneurysm, arteriovenous fistula,
major vessel injury with mechanical effect of the
catheter, aortic dissection, spinal cord ischemia, and
malperfusion of visceral organs. Balloon-related
complications include dislocation or migration of
the balloon, balloon rupture which may lead to
gas embolization, anemia, and thrombocytopenia
resulting from trauma to erythrocytes and platelets
with mechanical effect. In addition, IABP catheterrelated
local wound infections and systemic infections
among the rare complications which should be kept
in mind.[
6,
8-
12] In the literature, IABP complications
are similar to those reported in our study population.
Among the patients with IABP inserted in the OR,
critical leg ischemia was observed in two patients and
retroperitoneal hematoma due to vascular trauma in
one patient. In addition, local wound infection was
observed in one patient in each group, and was taken
under control with antibiotherapy without any need for
surgical debridement.
In the vast majority of patients with
IABP inserted, laboratory investigations yield
abnormalities.[13,14] Inflation and deflation in the
balloon catheter with the mechanical effect cause
trauma to platelets and erythrocytes. This situation
manifests as thrombocytopenia and anemia. Studies
conducted by Bream-Rouwenhorst et al.[14] and
McCabe et al.[13] demonstrated that the most common
side effect of IABP was thrombocytopenia, which
was reported in 47 to 82% of patients. Similar results
were also obtained in our study. Thrombocytopenia
was observed in 85.7% of the patients 24 hours after
the procedure. Furthermore, when the patients who
received IABP in the OR and those who received IABP
in the ICU were compared, the relative decrease in the
platelet counts was statistically significantly higher in
the in patients undergoing IABP in the OR setting
(p<0.005). This difference, undoubtedly, is largely due
to the exposure of cardiopulmonary bypass during
open heart surgery. In addition, nine patients (18.7%)
in Group 1 underwent mediastinal re-exploration due
to bleeding revision and eight (88.9%) of these patients
had thrombocytopenia. Therefore, it should be kept in
mind that thrombocytopenia may cause redo surgery and an increased amount of blood transfusion due to
postoperative bleeding in patients undergoing open
heart surgery and it may further complicate the clinical
picture of patient.
When used at an early stage and timely in an
appropriate location and in a proper way, IABP assists
both the patient and the surgical team. Therefore,
mortality and morbidities, length of stay in the ICU,
duration of mechanical ventilation, and location and
timing of IABP application have been repeatedly
investigated and the discrepancies among the studies
have been a subject of many clinical studies. In a
study, Torchiana et al.[15] classified the location of
IABP insertion as medical intensive care, surgical
intensive care, and OR and included these locations in
the multivariate analysis for mortality predictors. The
authors reported that early decision for IABP insertion
and performing percutaneous IABP insertion in the
preoperative ICU setting reduced mortality. In parallel
with this finding, Christenson et al.[16] and Metz et
al.[17] also found more promising results in terms of
mortality, duration of mechanical ventilation, and
length of stay in the ICU in patients with IABP
inserted preoperatively in the ICU. In our study,
the mean length of stay in the ICU in the patients
with IABP inserted was found to be 7.5 days in
Group 1 and 7 days in Group 2, indicating no
statistically significant difference. Also, there was no
statistically significant difference in the total duration
of mechanical ventilation between the groups. The
rate of mortality was found to be 39.6% in Group 1 and
56.5% in Group 2.
Nosocomial infections seen in patients followed
with IABP are rarely associated with the IABP
catheter alone. Since patients subjected to IABP
support usually have more than one monitoring lines in
addition to the balloon pump, it should be kept in mind
that the presence of these lines is an additional factor
in the frequency of fever and bacteremia. Review of the
literature reveals the increased incidence of nosocomial
infections in patients with IABP insertion.[10,11] In
the studies by Beckman et al.[12] and McCabe et al.[13]
evaluating the complications of IABP, the incidence of
local wound site infection was found to be 2.2 to 5%.
In a study by Pawar et al.[18] including 136 patients
with IABPs inserted, the most common systemic
infection resulted from the respiratory system and this
was attributed to the increased incidence of atelectasis
and superinfection in patients who were unable to be
mobilized while under the support of IABP. In another study by Goldberg et al.[19] with 101 patients comparing
percutaneous and surgical techniques, the rates of local
(2%) and systemic (4%) infections were found to be
higher in patients undergoing the surgical method. In
many studies conducted, it has been demonstrated that
the frequency of infections associated with IABP was
directly proportional to the duration of IABP therapy
and it has been suggested that the IABP catheter as
well as all invasive lines should be removed as soon
as possible to avoid this complication. In our study,
local wound infection was observed in the femoral
region where the IABP catheter was applied in one
patient in each group, and this was controlled with
proper antibiotherapy without any need for surgical
debridement. Although no significant difference was
found between the groups in terms of fever and the use
of antibiotics, pathogens were isolated in the catheter
tips sent to the laboratory in 11 patients (22.9%) from
Group 1 and 11 patients (47.8%) from Group 2, which
was found to be statistically significant (p=0.034). It is
clear that the main reason for this result is the sterile
environment provided by the operative conditions in
the patients where the insertion was performed in the
OR. Although IABP catheters were inserted in the
ICU conditions under aseptic conditions, the results
indicate that these efforts are not as reliable as those of
the OR conditions.
The limitations of this study are its retrospective
design and small sample size. On the other hand, the
fact that makes our study valuable is the microbiological
assessment of pathological growth in the samples
collected from the catheter tips after termination
of IABP therapy which was performed using the
same technique in the ICU or in the OR after the
termination of IABP treatment. To the best of our
knowledge, this is the first study in this regard in the
literature.
In conclusion, in our study, complications of intraaortic
balloon pump application, which has been
increasingly used due to the ease of use and relatively
low cost in low cardiac output syndrome, were
examined in great detail. However, it is noteworthy
that significant differences were found in the outcomes
of catheter cultures, although strict asepsis was
followed in our intensive care unit and the experience
of the team which performed the insertion procedures
and undertook care of the patients. Therefore, to
reduce infective complications of intra-aortic balloon
pump, all intra-aortic balloon pump catheters can
be considered to be inserted in the operating rooms setting. Nonetheless, further large-scale, prospective,
randomized-controlled studies are warranted to gain a
better understanding on this topic.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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