David Bregman

Percutaneous intraaortic balloon insertion

A new single chambered percutaneous intraaortic balloon has been constructed around a central guidewire. The balloon can be wrapped around the guidewire, enabling its insertion into the femoral artery through a 12F sheath inserted with the conventional Seldinger technique. Percutaneous intraaortic balloon insertion has been performed in 27 patients (mean age 58 years) for a variety of medical and surgical indications. Percutaneous balloons could not be advanced into the aorta in two patients (7.4 percent) with severe bilateral aortoiliac occlusive disease. In all 25 patients undergoing intraaortic balloon pumping satisfactory circulatory support was achieved, and 21 (84 percent) of the patients survived to be discharged from the hospital. The mean duration of intraaortic balloon pumping was 3.5 days. Percutaneous intraaortic balloon insertion requires less than 5 minutes and has been successfully performed in the cardiac catheterization laboratory, coronary care unit, operating room and recovery room. After direct balloon removal, external pressure was applied for 30 minutes. No patient experienced hematoma of the groin, aortic dissection, compromised distal pulses or late wound complications. Percutaneous balloon insertion permits the rapid institution of circulatory support and broadens the medical and surgical applications of intraaortic balloon pumping.

Percutaneous Intraaortic Balloon Pumping: Initial Clinical Experience

A new intraaortic balloon is described that can be inserted percutaneously through a 12F sheath by the standard Seldinger technique. Insertion and removal are rapid, and the hemodynamics of balloon pumping are similar to our previous clinical experience with standard single- and dual-chambered intraaortic balloons. The initial clinical experience is detailed.

A Pulsatile Assist Device (PAD) for Use During Cardiopulmonary Bypass

A pulsatile assist device (PAD) has been developed to convert roller pump flow to pulsatile flow in a simple fashion. The device can also be used as an arterial counterpulsator before and after cardiopulmonary bypass. The PAD has been used in 125 adult patients undergoing open-heart operations for coronary artery or valvular heart disease or the combination. Ninety-two patients were in New York Heart Association Functional Class III or IV or had ejection fractions of less than 0.3. The PAD functioned as a hemodynamically effective arterial counterpulsator before and after perfusion. All patients were successfully weaned from bypass with the PAD. There has been 1 intraoperative death and 2 late deaths. Only 1 patient had a perioperative myocardial infarction, and this person was successfully treated with intraaortic balloon pumping. We believe the PAD is a simple and reliable device for intraoperative counterpulsation and for the creation of pulsatile cardiopulmonary bypass. More important, use of the PAD may decrease both the incidence of perioperative myocardial infarction and the need for postoperative intraaortic balloon pumping.

Intraoperative Application of Intraaortic Balloon Counterpulsation Determined by Clinical Monitoring of the Endocardial Viability Ratio

Persistent unrecognized subendocardial ischemia with development of subendocardial necrosis is a major cause of patient death following cardiopulmonary bypass. The lesion is caused by a discrepancy between the oxygen needs of subendocardial muscle and the available blood supply. If sole reliance is placed upon monitoring conventional vital signs, the more subtle factors contributing to decreased blood flow may go unrecognized. Reported studies have confirmed that the adequacy of subendocardial perfusion can be predicted by calculating the supply/demand ratio, defined as the ratio of the diastolic pressure-time index (DPTI) divided by the systolic pressure-time index (TTI). An analog computer was designed and built that measures the area under the systolic and diastolic component, calculates the DPTI/TTI ratio, and digitally displays the result as the endocardial viability ratio (evr). The EVR was used to determine the adequacy of left ventricular subendocardial blood flow in 64 consecutive patients undergoing cardiac operations. Unidirectional intraaortic balloon counterpulsation (IABC) was utilized in 14 patients with 9 long-term survivors. The difference in mean EVR between survivors and nonsurvivors at the initiation of balloon support was statistically significant. Early application of unidirectional IABC when subendocardial ischemia persists following open cardiac procedures may prevent deterioration to subendocardial necrosis with subsequent morbidity or mortality.

A simple method to facilitate difficult intraaortic balloon insertions.

Abstract Intraaortic balloon pumping (IABP) is the supportive treatment of choice for the management of refractory left ventricular power failure. Concurrent arteriosclerotic disease, however, may make balloon insertion difficult. A new technique of insertion is described in which the proximal dual-chambered balloon is bent to facilitate the negotiation of tortuosities and arteriosclerotic junctures, thereby broadening the application of clinical IABP.

Intraoperative Autotransfusion During Emergency Thoracic and Elective Open-Heart Surgery

Abstract Massive intraoperative autotransfusion (average 7,200 ml.) was carried out in 5 patients with major thoracic trauma. All patients survived, but 3 required reoperation for postoperative bleeding associated with thrombocytopenia and low serum fibrinogen. Three patients underwent repair of complex congenital cardiac anomalies utilizing cardiopulmonary bypass. Excessive bleeding from cloth conduits, suture lines, and bronchial mediastinal collaterals precluded decannulation. Autotransfusion was begun as a preliminary to protamine administration; within 30 minutes autotransfusion was discontinued concurrent with hemostasis. All 3 patients survived. It is concluded that if the problems attendant upon autotransfusion are understood, the procedure can be a valuable, lifesaving adjunct in the management of major thoracic bleeding.

Superior mesenteric artery obstruction by intraaortic counterpulsation balloon simulating embolism: A case report

The use of intraaortic counterpulsation balloons has been lifesaving in patients with cardiogenic shock, and indications for its use have expanded in recent years. Several complications of catheter placement and use have been reported. We report what we believe is the first instance of simulated embolization of the superior mesenteric artery by a balloon that was intermittently occluding the vessels origin.

Current Status of Percutaneous Intra-Aortic Balloon Pumping

In 1982 it was estimated that one and a half million American sustained an acute myocardial infarction.[1] In the same year more than 100,000 cardiac surgical procedures were performed.[2] The development of direct techniques for coronary revascularization has resulted in a multitude of critically ill patients requiring open heart surgery. In an effort to deal with the increasing numbers of patients who present with the many complicated patterns of coronary artery or valvular heart disease, or both, and require urgent open heart surgery, a spectrum of cardiac support measures, ranging from simple pharmacologic maneuvers to a variety of mechanical assist devices, have been devised.