Critical Care Medicine-Neurologic Disorders>>>>>Mechanical Circulatory Support and the Transplanted Heart
Question 2#

A 78-year-old male is admitted to the ICU to undergo evaluation for urgent coronary artery bypass grafting after a coronary angiography revealed critical left main artery stenosis. During the catheterization procedure, an IABP was placed via the left common femoral artery because of ongoing chest pain. Chest pain abated after the IABP was placed. After several hours in the ICU, the patient complains of mild recurrent chest pain, and his nurse reports that there is new blood that can be seen in the IABP catheter that is connected to the console.

Which of the following is the most appropriate next step in the management of this patient?

A. Chest X-ray to confirm IABP placement
B. Urgent transthoracic echocardiogram
C. Repeat coronary angiography
D. Removal of the IABP
E. Abdominal CT scan

Correct Answer is D

Comment:

Correct Answer: D

Although the IABP is a widely used tool in the management of a variety of acute cardiac conditions, it is associated with complications occasionally. The presence of blood in the IABP catheter indicates balloon rupture, and the device should be immediately removed. Rarely, balloon rupture can result in thrombosis or balloon entrapment within the arterial tree and may require surgical exploration for safe removal. Blood in the IABP catheter is clearly indicative of balloon rupture, and no other investigations are necessary for diagnosis. Other important complications of IABP use include limb ischemia, vascular laceration, and hemorrhage. In one large review of 17,000 patients who underwent IABP placement, 7% of patients had at least one complication, whereas 2.6% suffered a major complication (acute limb ischemia, balloon rupture, significant bleeding, or death related directly to the IABP). 

References:

  1. Ferguson JJ III, Cohen M, Freedman RJ Jr, et al. The current practice of intra-aortic balloon counterpulsation: results from the Benchmark Registry. J Am Coll Cardiol. 2001;38:1456.
  2. Mihatov N, Dudzinski DM. Intraaortic balloon pump rupture. J Invasive Cardiol. 2015;27(9):E203.