A complication of an axillary intra-aortic balloon pump

Abstract

Intra-aortic balloon pumps (IABPs) are used to mechanically temporize a failing heart by decreasing afterload while increasing coronary perfusion pressure of the heart while more definitive treatment is sought. We report a case of a 65-year-old male with nonischemic cardiomyopathy, atrial fibrillation, thyroiditis, and non-Hodgkin lymphoma who presented with worsening heart failure. He underwent a percutaneous placement of a left axillary IABP with seemingly no complications. Approximately 3 weeks post-placement, the patient was taken for a heart transplant when an intraoperative transesophageal echo showed that the IABP was in the aortic arch and ascending aorta, instead of its proper placement in the descending aorta. The patient's arterial line showed waveforms appropriate for an IABP patient, and the patient showed no signs indicative of improper placement. This erroneous placement carried the potential to affect the aortic valve function, injure the aortic intima and/or occlude the aortic arch vessels. .

Keywords: ascending aorta mass; descending aorta; intra-aortic balloon pump (IABP); intra-aortic balloon pump complication; intra-aortic balloon pump malposition; transesophageal echo.

Figure 1

Transesophageal image of the aortic root and ascending aorta with IABP present.

Figure 2

Transesophageal image of the ascending and descending aorta with mispositioned IABP present.

Figure 3

Illustration of a normal IABP arterial waveform with IABP augmentation of diastolic and systolic pressures and normal IABP pressure waveform corresponding to inflation and deflation of the device with a distinctive pressure plateau. A = unassisted heart beat arterial pressure waveform; B = IABP generated arterial pressure waveform; C = assisted heat beat arterial pressure waveform; D = IABP balloon inflation pressure waveform; E = IABP balloon deflation pressure waveform.

Figure 4

Initial CXR: note the proximal and distal radiopaque markers of the IABP are visualized a few centimeters (5.1 cm) from each other; the proximity of the two markers indicates that along the path of the IABP, it has folded over itself causing the two markers to be abnormally close, as the 8Fr. balloon is 258 mm long, thus the markers should be separated by that much.

Figure 5

CXR done 21 days later, which shows the markers still not properly placed but the distance is about the same (5.8 centimeters) as the original position; additionally, the shadow of the inflated helium balloon can be seen in the ascending and aortic arch.