Re: Is heparin needed for patients with an intra-aortic balloon pump?
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ABSTRACT: We addressed the question of whether or not the currently available evidence base supports heparinization in the context of a patient requiring cardiovascular support with an intra-aortic balloon pump (IABP). A best evidence topic was written according to a previously defined structured protocol. A literature search returned 443 papers, 3 of which were deemed relevant. Jiang et al. randomized 153 patients requiring IABP to heparin or no heparin, matched for age, sex and comorbidities. There was no significant difference in limb ischaemia; however, incidence of bleeding was significantly increased in the heparinized group (14.1 vs 2.4%). One cohort study compared two management strategies of IABP in which patients either received heparin universally or selectively with heparin only given for certain pre-defined indications. They reported increased bleeding with universal heparinization (39.2 vs 31.8%) but similar other complication rates. Another cohort study in which patients with IABP were initially treated with glycoprotein IIb/IIIa antagonists only, reported bleeding and ischaemia rates within accepted ranges for heparinized patients. The use of anticoagulation with IABP is intended to reduce the risk of thrombus, thromboembolus or limb ischaemia whilst generating an increased risk of bleeding as a side-effect. The aforementioned studies demonstrate that omitting or implementing a selective use strategy of heparinization during IABP counterpulsation can significantly decrease the incidence of bleeding without an increase in ischaemic events. One study also performed angiography prior to IABP insertion on some of their patients, selecting the less diseased side to insert the IABP. Current evidence on this topic is sparse, especially as relates to patients in the context of cardiothoracic surgery. Just one study specifically looked at surgical patients. However, the existing data suggest that it is safe to omit heparinization when using IABP counterpulsation. The decision to heparinize should be weighed in the context of other indications or contraindications rather than being an automatic response to the use of IABP.Interactive Cardiovascular and Thoracic Surgery 04/2012; 15(1):136-9. · 1.11 Impact Factor
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ABSTRACT: The aim of this study was to assess the risk of intra-aortic balloon counterpulsation and to identify clinical and procedural variables that would predict complications. We analysed 381 consecutive patients who were treated between 1977 and 1995 at our catheterization laboratory and/or medical intensive care unit. The complications considered relevant were limb ischaemia requiring catheter removal, vascular injury, bleeding requiring transfusion, embolic events, and infection. In eight patients the balloon could not be inserted. The rate of complications for the remaining 373 patients was 12.9%. Between 1977 and 1980, surgical insertion was performed using a 12 French catheter with a complication rate of 30.4% (seven of 23 patients). Percutaneous implantation, performed after 1981, had an overall complication rate of 11.7% (41 of 350 patients). Using thinner catheters for percutaneous placement was associated with a reduction in the rate of complications, from 20.7% (17 of 82 patients) for 12 French catheters to 9.9% (10 of 101 patients) for 10.5 French catheters (P = 0.04), and 8.4% (14 of 167 patients) for 9.5 French catheters (P = 0.006). Multivariate logistic regression analysis identified duration of counterpulsation > 48 h (odds ratio 3.6), catheter size (odds ratio 3.4 for 12 French catheters), peripheral vascular disease (odds ratio 2.7), and shock (odds ratio 2.0) as independent risk factors for counterpulsation-associated complications. When considering 9.5 French catheters only (167 patients, all after 1992), the sole remaining independent risk factor was duration of counterpulsation > 48 h (odds ratio 3.8). Those patients with 9.5 French catheters in whom counterpulsation did not exceed 48 h had a low complication rate of 3.9%. The rate of percutaneous intra-aortic balloon counterpulsation complications was thus significantly reduced by employing thinner catheters. It was at an acceptable level for 9.5 French catheters, where a long duration of counterpulsation emerged as the most significant factor associated with complications. Whether using even thinner catheters in combination with a sheathless implantation technique further minimizes the risk of counterpulsation remains to be seen.European Heart Journal 03/1998; 19(3):458-65. · 14.72 Impact Factor
eComment. Re: Is heparin needed for patients with an intra-
aortic balloon pump?
• Kelechi E. Okonta
• Umar Abubakar, Emeka B. Kesieme, Peter O. Adeoye
Division of Cardiothoracic surgery, University College Hospital Ibadan, Ibadan, Nigeria
Re: "Is heparin needed for patients with an intra-aortic balloon pump?" Pucher, et al.,
Interactive CardioVascular and Thoracic Surgery doi:10.1093/icvts/ivs197
© The Author 2012. Published by Oxford University Press on behalf of the European
Association for Cardio-Thoracic Surgery. All rights reserved
The article by Pucher et al.  showed the expected results of heparin need for patients with an
intra-aortic balloon pump (IABP). At the same time, they observed that the use of heparinization
with IABP, which was intended to reduce the risk of thrombus, thromboembolus or limb
ischaemia, will concomitantly increase the risk of bleeding as a side-effect. They therefore
concluded from the studies that omitting or implementing a selective use strategy of
heparinization during IABP counterpulsation could significantly decrease the incidence of
bleeding without an increase in limb ischaemic events.
It is important to state that the use of IABP showed be holistic, especially when considering
ischaemic complications such as limb ischaemia. While it is true that judicious use of an adjunct
like heparin should be seriously considered in light of the attendant complications, the physical
properties of the IAPB should also be seriously considered vis a vie the size of the
balloon/catheter and sheathless technique. In particular, the height/ body surface area of the
patients should be taken into account to avoid the occlusive effect of the balloon/catheter, which
can lead to an increased effect of limb ischaemia. Scholz et al. observed that using thinner
catheters for percutaneous placement was associated with a reduction in the rate of
complications, from 20.7 % (17 of 82 patients) for 12 French catheters to 9.9 % (10 of 101
patients) for 10.5 French catheters (P= 0.04), and 8.4 % (14 of 167 patients) for 9.5 French
catheters (P=0.006) and with multivariate logistic regression analysis identified catheter size
(odds ratio 3.4 for 12 French catheters) and other factors were independent risk factors for
counterpulsation-associated complications. Nash et al., whilst stating that IABP was helpful
for controlling myocardial ischaemia and providing haemodynamic support, pointed out that its
applicability was limited by lower extremity ischemic complications in a significant percentage
of patients. They developed a new sheathless technique for percutaneous intra-aortic balloon
catheter insertion, which reduced the effective catheter size. A pilot study conducted using this
new technique resulted in a 10% rate of limb ischemia, without compromise of balloon function.
They concluded that the technique was useful in reducing the incidence of limb ischaemia
associated with IAPB .
Thus in the use of IAPB, especially when heparinization is to be discouraged or omitted for fear
of bleeding, the balloon/catheter size, and possibly the avoidance of a sheath should be
 Pucher PH, Cummings IG, Shipolini AR, McCormack DJ. Is heparin needed for patients with
an intra-aortic balloon pump? Interact CardioVasc Thorac Surg 2012;doi:10.1093/icvts/ivs017.
 Scholz KH, Ragab S, von zur Muhlen F, Schroder T, Werner GS, Mindel L et al.
Complications of intra-aortic balloon counterpulsation The role of catheter size and duration of
support in a multivariate analysis of risk. Euro Heart J 1998;19:458-465.
 Nash IS, Lorell BH, Fishman RF, Baim DS, Donahue C , Diver DJ. A new technique for
sheathless percutaneous intraaortic balloon catheter insertion. Cathet Cardiovasc Diagn
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Published April 18, 2012