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
Conflict of Interest:
Read all letters published for this article
Published April 18, 2012