Original Article

The role of the intra-aortic balloon pump counterpulsation (IABP) in emergency surgery

A.L. Khan M. Flett S. Yalamarthi R.R. Jeffrey* A.K. Ah-See K.G.M. Park R.A. Keenan
University Department of Surgery, *Department of Cardiothoracic Surgery, University of Aberdeen, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, U.K.
Correspondence to: A.L. Khan, Hairmyers Hospital, Eaglesham Road, East Kilbride, G75 8RG, U.K.

Introduction Case report 1 Case report 2

Case report 3 Discussion References

Keywords: Emergency abdominal surgery, myocardial infarction, intra-aortic balloon pump 
Surg Edinb Irel., 1 October 2003, 279-282

Elective surgical procedures are often delayed for up to six months in patients who have suffered a myocardial infarction (MI) because of the substantial risk of re-infarction and high peri-operative mortality. The optimal management of patients who have sustained a recent myocardial infarction and who require an emergency abdominal operation, however, has yet to be defined. The use of an intraaortic balloon pump (IABP) may play a role in such patients by improving the function of the injured heart. Three cases are presented in which IABP was used in patients who had recently sustained a myocardial infarction and who required emergency abdominal surgery. A review of the literature is presented and the application of IABP in such circumstances is discussed. Although clinical experience is limited, the use of the IABP may be useful in selected patients who have sustained a recent MI and who require emergency surgery

INTRODUCTION
Intra-aortic balloon pump is a mechanical, circulatory device, which was introduced in 1962. This pump is often placed percutaneously into the common femoral artery which allows the balloon to be positioned in the aorta. During diastole, the balloon is inflated leading to an increase in the aortic diastolic pressure. This leads to an augmentation of the coronary artery blood flow resulting in an increase in myocardial oxygen supply without an increase in myocardial workload. In systole, the balloon is deflated and this leads to a reduction in aortic root pressure. This produces a reduction in the after load. In turn, this reduction in workload of the left ventricle decreases myocardial consumption and increases the cardiac output. The use of this device was initially restricted to the management of patients suffering from complications of MI. Indications for its application, however, continue to evolve. Several reports describing the use of IABP in patients with cardiac disease and who require abdominal surgery can be found in the American literature, but there is a paucity of such reports in the European literature. Three cases are reported of patients who had either sustained a recent MI or suffered from severe myocardial ischaemia and who required an emergency abdominal operation; IABP was used in each case. A literature review of the use of IABP in such circumstances is discussed.

CASE REPORT 1
A 57-year-old man with a past medical history of severe hypertension, congestive cardiac failure, hypothyroidism and left nephrectomy (aged four following an accident) was admitted with signs and symptoms suggestive of an incarcerated incisional hernia. Shortly after admission, the patient sustained an acute anterior MI. His abdominal condition settled with conservative management and it was decided to defer repair of the incisional hernia for six months.

The patient, however, was re-admitted two months later, with a further incarceration of the hernia. Shortly after admission, the patient had another acute MI, this time complicated by a cardiac arrest.

Following resuscitation, cardiac catheterisation revealed significant ‘three-vessel’ disease. Percutaneous transluminal coronary angioplasty was planned but, unfortunately, the abdominal symptoms and signs deteriorated to an extent that emergency surgery was indicated.

An IABP was inserted immediately prior to surgery for repair of his hernia. A marked improvement in cardiac function was achieved allowing laparotomy to be performed. This revealed an intraloop abscess associated with a localised perforation of small bowel. Resection of this segment of small bowel was performed and the hernial defect repaired.

Invasive haemodynamic monitoring was continued for several days while the IABP remained in place.

The pump was removed after 48 hours and the patient went on to make an uneventful recovery. Cardiac surgery was not contemplated for the immediate future, as his cardiac condition remained stable on appropriate medical therapy.

CASE REPORT 2
A 72-year-old man was admitted to the coronary care unit with unstable angina following a MI. His past medical history included four previous MIs. On this occasion, cardiac angiography revealed severe diffuse coronary artery disease with stenosis of all major vessels. Two weeks later, the patient developed a small bowel obstruction that failed to resolve with conservative management.

An IABP was inserted in an attempt to improve cardiac function and the patient proceeded to laparotomy. An internal hernia was released and the bowel was viable. Four days later, a coronary artery by-pass graft with endarterectomy was undertaken. The IABP was removed on the fifth post-operative day. Two days later the patient developed episodes of dysrrythmia including a cardiac arrest due to ventricular fibrillation. Following resuscitation, the patient responded to medical management and was discharged two weeks later.

CASE REPORT 3
A 66-year-old man was admitted with an episode of unstable angina and atrial fibrillation. He had undergone cardiac catheterisation three months earlier that showed ‘triple’ vessel disease and a significant left main stem stenosis. It was also noted that he had a calcified aortic valve that produced significant stenosis. Two weeks after admission, and while awaiting semi-elective cardiac surgery, the patient developed abdominal pain and ischaemic bowel was suspected. An IABP was inserted prior to laparotomy. The small bowel appeared slightly dusky but as it was felt to be viable that no definitive procedure was performed. He was weaned off inotropic support and the IABP removed after 48 hours. This was followed by a period of dysrrythmia that appeared to be controlled with appropriate medication. Unfortunately, by the eighteenth day his cardiac condition had deteriorated and, despite further IABP support, he died.

DISCUSSION
Goldman et al. (1977) showed that a healthy adult undergoing a non-cardiac operation had less than 1% risk of sustaining a MI.¹ Patients with a cardiac condition, however, are at a greater risk from surgery and anaesthesia.² A patient with a past history of MI has a 7% chance of reinfarcting.³ This risk increases to 26% and 37%, if the previous infarction occurred within 4-6 months and 0-3 months, respectively.⁴ It is not just patients with MI who are at high risk. Patients who have had angiographic evidence of severe coronary artery disease, ischaemia on stress testing or who have unstable angina are at increased risk. Mahar et al. (1978) has shown a 20% infarction rate in patients with ‘three-vessel disease’.⁵ It has been suggested that reinfarction can be reduced from 37% to 6% in patients undergoing non-cardiac surgery and who had sustained a MI within three months or less previously.⁴ This was achieved by careful attempts to improve pre-operative cardiac status and monitoring during the surgical procedure.⁶ Despite these manoeuvres there remains a 36% mortality rate in this group of patients.

This unsatisfactory situation has led to the policy of deferring surgery in these ‘high-risk’ patients whenever possible, preferably for several months or at least until they have undergone corrective cardiac surgery. It is easier to maintain such a policy in patients requiring elective surgery, but in the emergency situation the decision becomes much more difficult. This delaying policy would have been impossible to implement in our three patients as the surgical problems in themselves were life-threatening. Cardiac complications occur more frequently in patients who require emergency surgery. The reasons for this are thought to be a combination of fluid shifts, blood loss and long periods of mechanical ventilation.

Goldman et al. (1977) have developed a multifactorial risk index that allows patients to be stratified into four groups.¹ This allows for the probability of post-operative cardiac death to be predicted. Such criteria include a history of a myocardial infarction within six months, the presence of an arrhythmia and the need for emergency surgery. Our three patients described here would be in Goldman class IV, the highest risk category.

The use of IABP has mainly been in patients with persistent cardiac failure after cardiopulmonary bypass, refractory angina or following the complications of MI.⁷ Several reports of its use in other circumstances began to appear in the American literature in the mid 1970s.^8,9

Cohen and Weintraub in 1975 operated on a man who had sustained a recent MI and was bleeding from a gastric ulcer.⁸ The use of IABP contributed to a successful outcome. This report was followed in 1976 by the description of Foster et al. (1976) of its use in three patients with severe cardiac disease who required abdominal surgery.⁹ The first patient had sustained a recent MI and was found to have a renal tumour. The second patient, an 88-year-old man was admitted with angina and melaena. He underwent a sigmoid colectomy for haemorrhage from diverticular disease. These two patients survived but, unfortunately, the patient who required emergency surgery died of renal failure. This was a lady who had undergone mitral valve replacement and sustained a major post-operative bleed from an acute duodenal ulcer requiring major gastric surgery.

Georgen et al. (1989) looked at the results of IABP in 15 patients undergoing cholecystectomy.¹⁰ Nine patients had acute disease requiring urgent surgery while six patients with chronic problems had an elective approach. All patients had suffered a MI within the previous two months and were considered to be in the Goldman class IV group and at high risk of re-infarction. There were no intra-operative deaths, but two patients died from arrhythmias on day one and day nine. They concluded that IABP was a safe and effective technique in biliary surgery in high-risk patients. Grotz and Yeston et al. (1984) carried out pre-operative IABP in high-risk cardiac patients undergoing non-cardiac surgery with satisfactory results.¹¹ More recently, Masaki et al. (1999) used IABP successfully in two patients with severe three vessel disease undergoing emergency intra-abdominal surgery.¹² The largest report on the use if IABP was from Shayani et al. (1998) who described 68 patients who required laparotomies.¹³ They divided them into three groups. The first comprised 29 patients in which IABP was placed preoperatively to optimise cardiac function. Three patients in this group who required emergency surgery died, but there were no deaths in the elective group. Group two comprised ten patients who were in cardiogenic shock. Again the emergency cases fared badly with five out of six dying. The final group had the IABP inserted to improve cardiac function and then the device was removed within 30 days of surgery. Of the 29 patients, 18 were in need of urgent or emergency surgery and 18 (62%) died. It appears from this large report, that the use of IABP may not prevent death in those patients who are in need of emergency surgery. Sui et al.(1991) supported this view when they pointed out that in their series of eight patients, two of the three patients who were in need of emergency surgery died.¹⁴ Intra-abdominal sepsis was present in both cases and this may be an important factor in patient survival. Sepsis can lead to major fluid shifts and myocardial depression. However, it can be argued that if surgery is not performed in such patients death would have been inevitable. This would certainly have been the case in two of our patients.

As in one of the cases presented, serious arrhythmias can occur in the post-operative period and have been reported in all series. Continuous monitoring is essential if they are to be detected and treated promptly. In patients with IABP, haemodynamic assessment requires careful monitoring with single or multiple ECG leads, pulmonary capillary wedge pressure, arterial pressure and arterial oxygen saturation measurements.

It is interesting to note that there are no reports of intraoperative deaths while the IABP is in situ. It is only when the pump has been removed that problems seem to occur, but the timing of its removal is unclear. Weitz and Goldman et al. (1987) pointed out that the risk of an MI can persist until the fifth or sixth post-operative day.¹⁵

The IABP consists of a slender polyurethane balloon mounted on a catheter. The balloon catheter is inserted into the patient’s aorta either surgically or per-cutaneously by the seldinger approach. The common femoral artery is customarily used for this purpose although it may be introduced via the subclavian or iliac artery.The procedure is performed under fluoroscopic guidance.¹⁶ The IABP may be inserted directly into either the ascending aorta or transverse arch in patients who have an abdominal aortic aneurysm or severe peripheral vascular disease.

Although several authors suggest that the technique is safe, complications have been described.⁷ Christenson et al. (2002) showed an overall complications rate of 6.5% and a major complication rate of 2.1%.¹⁷ Others have identified the risk factors associated with high morbidity and mortality.^7,18 Georgeson et al. (1992) assessed the complications in 1505 patients having percutaneous insertion of IABP.¹⁹ The pump could not be inserted in 6% of patients, despite bilateral attempts. Some 18.6% of patients had complications which resulted in limb ischaemia of whom 46% required surgical intervention. Amputation was necessary in 6% of cases. In their review, they found 10 deaths related to the use of IABP. Long-term complications such as rest pain, thromboembolic events, dissection of the femoral artery and false aneurysm were reported. They emphasised that these patients all had pre-existing peripheral vascular disease and care has to be exercised in the technique of insertion and removal of the pump. Shayani et al. (1998) report that they found that 13 patients had complications: 11 patients had thromboembolism and 2 patients had sepsis. Major limb ischaemia occurred in 2 patients, but there were no deaths.¹³ Removal of the pump in a patient because of ipsilateral leg pain and emergency surgery for lower limb ischaemia has been reported.^10,14 It was felt that the lack of anticoagulant use in the post-operative period accounted for much of these complications. This led the authors to change their policy of using anticoagulants in all cases of IABP use. Their incidence of complications was similar to that described by Mehlhorn et al (1999) and Christenson et al. (2001).^20,21

In conclusion, the use of an IABP may be a useful technique in patients who are so severely compromised by cardiac disease that any abdominal surgery would be extremely dangerous. Its use in semi-elective cases appears to be reasonably successful but in the true emergency setting, especially in cases of sepsis, the results may not be as satisfactory. However, in the three emergency cases described, the use of an IABP appeared helpful. General surgeons faced with the dilemma of severely compromised patients with cardiac disease requiring emergency surgery should consider its use.

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Copyright: 14 July 2003