Intra-aortic balloon pump can be used after acute type A aortic dissection repair

Abstract

Objectives

We analyzed our data to evaluate the safety and feasibility of intraoperative extracorporeal membrane oxygenation and intra-aortic balloon pump use in acute type A aortic dissection repair.

Methods

Between December 1999-December 2020, we identified patients who received intraoperative extracorporeal membrane oxygenation and/or intra-aortic balloon pump support to wean off cardiopulmonary bypass were retrospectively reviewed.

Results

A total of 690 patients who underwent acute type A dissection repair. In all, 31 patients received intraoperative circulatory support (11 extracorporeal membrane oxygenation, 20 intra-aortic balloon pump) to wean off cardiopulmonary bypass. In all, 14 patients (45%) were female and the median age was 65 years (interquartile range 51–73). Prior to the acute type A dissection repair, 13 (42%) had coronary malperfusion, 7 (23%) had visceral malperfusion, 4 (13%) presented with acute coronary syndrome, and 8 (26%) received cardiopulmonary resuscitation. The median clamp time was 108 min (interquartile range 89–157) and circulatory arrest time was 25 min (interquartile range 19–31). Concomitant procedures included 11 coronary artery bypass grafting (35%), 4 root replacements (13%) and 1 total arch replacement (3%). Overall, in-hospital mortality was 67%: 10 of 11 (91%) patients with extracorporeal membrane oxygenation and 11 of 19 patients (55%) with intra-aortic balloon pump expired. There were no intra-aortic balloon pump-specific aortic complications (i.e. aortic rupture, extension of dissection).

Conclusions

Outcomes after extracorporeal membrane oxygenation support in acute type A dissection were discouraging. There may be a role for intra-aortic balloon pump following acute type A dissection repair to allow patients to recover from cardiogenic shock in the selected patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-025-03556-x.

Background

Cardiogenic shock is a severe condition with high mortality after surgical treatment for acute type A aortic dissection (ATAAD) [1]. Historically, ATAAD has been considered as a contraindication to mechanical circulatory support. Especially prior to ATAAD repair, intra-aortic balloon counterpulsation may worsen aortic valve insufficiency. There is limited data available for the use of circulatory support, extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) to wean from cardiopulmonary bypass (CPB), particularly in patients with ATAAD. Many surgeons avoid IABP use in ATAAD from the concerns of aortic events, such as rupture and wall disruption [2, 3]. However, utility and safety of IABP as a salvage option for severe cardiogenic shock following ATAAD repair has also been reported [2, 4]. Wu et al. [5] demonstrated that all patients successfully underwent IABP implantation for ATAAD patients without IABP-related complications. ECMO is used in less than 1% of patients undergoing general open-heart surgery, and 31–76% are successfully weaned from the ECMO, with 50–60% of patients achieving survival at discharge from the hospital [6]. Considering the higher mortality and morbidity rates after ATAAD repair compared to other open-heart procedures, weaning from ECMO in ATAAD patients may be more challenging [7], even futile.

Sultan, et al. [7] reported that factors requiring ECMO support after open repair for type A dissection with biventricular dysfunction resulted in the hospital mortality of 87.5%. Thus, we evaluated the safety and feasibility of IABP and ECMO support in patients who had ATAAD repair.

Main text

This study utilized a historical cohort design, using risk factor and outcome data from our department’s prospective cardiovascular surgery registry. We retrospectively reviewed the institutional aortic database from December 1, 1999-December 31, 2020, to identify patients who intraoperatively received IABP and/or ECMO support after ATAAD repair. The indication of IABP and ECMO was determined by each surgeon. All the IABPs (34 cc size) were placed percutaneously from the femoral artery under transesophageal echocardiogram (TEE) guidance to confirm its positioning in the true lumen of the descending aorta, and distal to the left subclavian artery. The extent of dissection was evaluated by computed tomography and TEE. Even if the dissection extended to the descending aorta, IABP was considered indicated if the surgeon determined that left ventricular support was necessary. ECMO was initiated through central cannulation technique, in which the sidearm of the ascending aortic Dacron graft was utilized for arterial return and venous drainage through right atrial appendage to the inferior vena cava using staged cannula.

Surgical technique

Our protocol for open surgical repair of ATAAD has been described previously [8, 9]. The procedure involves the use of cardiopulmonary bypass, profound hypothermia, circulatory arrest, and retrograde cerebral perfusion. The patient is cooled until a nasopharyngeal temperature of between 15℃ and 20℃ is achieved. We maintain the pressure of the superior vena cava at less than 25 mmHg. The ascending aorta and lesser curve of the aortic arch are replaced with a Dacron graft (hemiarch repair). Complete replacement of the aortic arch is performed if it is aneurysmal or has an extensive primary tear. A side hole is created in the graft for the reattachment of the cerebral and subclavian vessels. Bleeding points are secured, cerebral perfusion is restarted, and systemic circulation is restored through a premanufactured sidearm attached to the graft.

The patient’s head is then elevated, and the body is rewarmed. Attention is then directed to the tubular portion of the ascending aorta, which is excised. The graft is sutured above the supracoronary ascending aorta. The aortic root is reconstructed, the valve is resuspended, and the reconstructed supracoronary ascending aorta is reattached to the graft. In cases where the aortic root is dilated, it is replaced with a composite valve graft prosthesis or reimplanted using valve sparing techniques. Once the patient’s core body temperature reaches 36℃, and they are able to maintain adequate systemic blood pressure and sinus rhythm, they are weaned from cardiopulmonary bypass.

Statistical methods

Descriptive statistics were computed using standard univariate measures of frequency and central tendency. A test for normality was done by the Shapiro-Wilk test using JMP software version 16 (SAS Institute Inc., Cary, NC).

Results

In all, 690 ATAAD repairs were performed during the study period, of which 31 patients (4.5%) required intraoperative circulatory support (20 IABP [2.9%], 11 ECMO [1.6%]) to wean off CPB. Fourteen patients (45%) were female and median age was 65 years (interquartile range, IQR:51–73). Prior to the repair, 13 (42%) had coronary malperfusion, 7 (23%) had visceral malperfusion, 4 (13%) presented with STEMI (all had coronary malperfusion), 8 (26%) were comatose, and 8 (26%) received cardiopulmonary resuscitation (3 of 8 patients had coronary malperfusion). All five of the remaining cases were associated with cardiac tamponade. Among them, three patients suffered aortic rupture during operating room preparation and were taken directly to salvage surgery. Pericardiocentesis was performed in the other two patients, one of whom underwent the procedure in part to allow for neurological assessment due to coma. Most of the patients had DeBakey type I aortic dissection, and only 2 of the IABP patients had type II, according to operative and preoperative CT imaging, including one with intramural hematoma. CT was only available for review in 8 of 20 IABP patients. Of these 8, proximal descending aorta size ranged from 29 to 44 mm and mid-descending aorta size were 29–36 mm. Other details of the preoperative patient characteristics are summarized in Table 1. Preoperative characteristics were similar in patients who received IABP and ECMO. When preoperative patient characteristics of those who received IABP and/or ECMO were compared to patients who did not receive mechanical support, we found those who did were significantly older, more frequently male, had lower left ventricular ejection fraction (%), higher serum lactic acid level, more frequently had history of coronary artery disease and previous sternotomy, more frequently required inotropes support, intubation, and cardiopulmonary resuscitation. (Supplemental Table 1) In addition, patients who received IABP and/or ECMO more frequently presented with malperfusion syndrome of the coronary, viscera, and kidney.

Table 1.

Preoperative patient characteristics

Patient Variable	All N = 31	IABP N = 20	ECMO N = 11
Age, years	65 (51–73)	66 (53–75)	63 (38–71)
Female	14 (45%)	10 (50%)	4 (36%)
Hypertension	23 (74%)	17 (85%)	6 (55%)
Diabetes mellitus	4 (13%)	2 (10%)	2 (18%)
CAD	13 (42%)	11 (55)	2 (18%)
COPD	10 (32%)	9 (45%)	1 (9%)
Cerebrovascular disease	4 (13%)	3 (15%)	1 (9%)
Peripheral arterial disease	4 (13%)	3 (15%)	1 (9%)
eGFR (mL/min/1.83m2)	45 (32–64)	42 (29–67)	48 (39–61)
ESRD on HD	2 (6%)	2 (10%)	0 (0%)
HAD/CTD	4 (13%)	1 (5%)	3 (27%)
History of sternotomy	5 (16%)	3 (15%)	2 (18%)
Prior procedures
TAAA repair	2 (6%)	2 (10%)	0 (0%)
CABG	4 (13%)	3 (15%)	1 (9%)
PCI	4 (13%)	3 (15%)	1 (9%)
ASD repair	1 (3%)	0 (0%)	1 (9%)
AVR	1 (3%)	1 (5%)	0 (0%)
On inotrope support	13 (42%)	9 (45%)	4 (36%)
Intubated	11 (35%)	8 (40%)	3 (27%)
Cardiopulmonary resuscitation	8 (26%)	6 (30%)	2 (18%)
Malperfusion
Coronary	13 (42%)	8 (40%)	5 (45%)
Visceral	7 (23%)	3 (15%)	4 (36%)
Renal	11 (35%)	6 (30%)	5 (45%)
Limb	7 (23%)	5 (25%)	2 (18%)
Tamponade	7 (23%)	5 (25%)	2 (18%)
Rupture	8 (26%)	5 (25%)	3 (27%)
STEMI	4 (13%)	3 (15%)	1 (9%)
Coma	4 (13%)	4 (20%)	0 (0%)
LVEF (%)	45 (35–60)	53 (34–60)	45 (38–58)
Diameter of the ascending aorta	50 (46–62)	50 (46–60)	49 (45–64)
GERAADA score	25 (15–63)	18 (13–67)	32 (23–74)

Continuous variables are expressed as median (interquartile range), categorical variables are expressed as number (%). P-Value is for the comparison of IABP and ECMO patients

CABG = coronary artery bypass grafting; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; CTD = connective tissue disorder; eGFR = estimated glomerular filtration rate; ESRD on HD = end stage renal disease on hemodialysis; GERAADA = The German Registry of Acute Aortic Dissection Type A; HAD = heritable aortic disease; LVEF = left ventricular ejection fraction; TAAA = thoracoabdominal aortic aneurysm

All the patients were indicated for IABP due to the left ventricular dysfunction, unable to wean off CPB, despite the use of equal to or greater than 2 pressors. The indications for ECMO were left ventricular dysfunction in 4 patients, right heart failure in 4 patients, and severe hypoxemia unable to wean off CPB in 3 patients. Of note, two patients were nonresponsive to IABP and were, thus, converted to ECMO. These two patients were counted as ECMO group. Intraoperative outcomes are demonstrated in Table 2. The median clamp time was 108 min (IQR: 89–157) and the median CBP time was 259 min (IQR: 204–326). The median circulatory arrest time was 25 min (IQR: 19–31). Concomitant procedures included 11 CABGs (35%) and 1 aortic valve replacement (3%). Regarding the extent of repairs, 4 root replacements (13%) and 1 total arch replacement (3%) were performed. TEVAR was performed on 1 of the IABP patients, due to persistent visceral malperfusion after the central repair. Open chest management was required in 30% of the IABP patients, while every patient on ECMO had the chest open due to the central cannulation. Only 2 of 11 patients were able to be weaned from the ECMO support, with ECMO support times of 6 and 7 days. Both patients had received ECMO for right ventricular heart failure. The two intraoperative deaths occurred in the IABP group both had preoperative CPR. After rewarming, there was no EEG activity and, due to the poor prognosis, the decision was made to withdraw at the point and not to convert to ECMO.

Table 2.

Intraoperative outcomes

Patient variable	Overall N = 31	IABP N = 20	ECMO N = 11
Extent of repair
Hemiarch replacement	30 (97%)	20 (100%)	10 (91%)
Total arch replacement	1 (3%)	0 (0%)	1 (9%)
Valve Procedure Types
Resuspension	26 (84%)	16 (80%)	10 (91%)
Aortic valve replacement	1 (3%)	1 (5%)	0 (0%)
Modified Bentall	4 (13%)	3 (15%)	1 (9%)
Concomitant procedures
CABG	11 (35%)	9 (45%)	2 (18%)
Cabrol shunt	3 (10%)	3 (15%)	0 (0%)
Exploratory laparotomy	5 (16%)	2 (10%)	3 (27%)
TEVAR	1 (3%)	1 (5%)	0 (0%)
Extra-anatomical bypass	2 (6%)	1 (5%)	1 (9%)
Open chest	17 (55%)	6 (30%)	11 (100%)
Aortic clamp time, min	108 (89–157)	106 (90–151)	108 (85–183)
Bypass time, min	259 (204–326)	245 (187–308)	311 (241–366)
Circulatory arrest time, min	25 (20–31)	24 (19–30)	27 (23–35)
Blood product
Cell saver, unit	5 (4–9)	5 (4–9)	6 (4–11)
pRBC, unit	9 (6–13)	9 (5–12)	8 (6–16)
FFP, unit	7 (4–12)	7 (4–12)	7 (4–16)
Factor VII use	5 (16%)	4 (20%)	1 (9%)
PCC use	1 (3%)	0 (0%)	1 (9%)
Coagulopathy	26 (84%)	16 (80%)	10 (91%)
Intraoperative death	3 (10%)	3 (15%)	0 (0%)

Continuous variables are expressed as median (interquartile range), categorical variables are expressed as number. P-Value is for the comparison of IABP and ECMO patients

CABG = coronary artery bypass grafting; FFP = fresh frozen plasma; pRBC = packed red blood cell; PCC = prothrombin complex concentrate; TEVAR = thoracic endovascular aortic repair

Postoperative outcomes are summarized in Table 3. The overall in-hospital mortality was 67%: 10 of 11 patients (91%) with ECMO, 11 of 20 patients (55%) with IABP expired during the hospital stay. In the ECMO group, four patients died of multi-organ failure (MOF), three from low output syndrome (LOS), two from anoxic brain injury, and one from intracranial hematoma. In the IABP group, five patients died from LOS, two from MOF, two from anoxic brain injury, one from cardiac arrest, and one from bowel necrosis. There were no IABP-specific aortic complications, such as aortic rupture, worsening of aortic regurgitation, or extension of aortic dissection. A patient on IABP developed arterial thrombosis in the cannulated limb, and the IABP was reinserted to the other limb and thrombectomy was performed. However, he expired from multiorgan failure the same day. In patients for whom CT follow-up was available, the median duration was 2.6 years (0.3–10.1 years). CT evaluation showed no differences in aortic diameter at the descending aorta when comparing before and after IABP use (n = 8, Supplemental Table 2).

Table 3.

Postoperative outcomes

Patient Variable	Overall N = 31	IABP N = 20	ECMO N = 11
Stroke	10 (32%)	3 (15%)	7 (64%)
Atrial fibrillation	4 (13%)	3 (15%)	1 (9%)
Respiratory failure	16 (52%)	7 (35%)	9 (82%)
Renal replacement therapy	14 (45%)	6 (40%)	6 (55%)
Bowel ischemia	2 (6%)	1 (5%)	1 (9%)
Deep vein thrombosis	2 (6%)	2 (10%)	0 (0%)
Re-exploration for bleeding	4 (13%)	0 (0%)	4 (36%)
Arterial embolization	1 (3%)	1 (5%)	0 (0%)
Discharged to home	3 (10%)	3 (15%)	0 (0%)
Discharged to rehab	7 (23%)	6 (40%)	1 (9%)
In-hospital mortality	21 (68%)	11 (55%)	10 (91%)
Time on support, days	2 (0–4)	1 (0–3)	3 (2–5)
Limited to survivors		2 (1–5)*	6**
ICU stay, days	5 (1–13)	3 (1–15)	5 (2–8)
Limited to survivors		14 (5–24)	42

Categorical variables are expressed as number (%). *, N = 9; **, N = 1

Respiratory failure = ventilation hours > 48 h, reintubation, or tracheostomy

P-Value is for the comparison of IABP and ECMO patients

Discussion

Our outcomes suggest that IABP can be used in patients after ATAAD repair without causing aortic rupture or wall disruption to recover the cardiac function. It should be recognized that IABP insertion was performed after central repair and correction of any aortic insufficiency. We had no aortic events, as was previously reported as a concern [2, 4, 5]. On the other hand, patients who required ECMO had poor outcomes. This is most likely because patients who received ECMO had more severe left ventricle dysfunction or “stone” heart, as two patients were converted from IABP support.

Also, the patients requiring ECMO for hypoxemia were patients who had received multiple blood products for rupture and had cardiopulmonary resuscitation prior to the ATAAD repair. This is similar to recent reports by Uehara and colleagues that patients who received cardiopulmonary resuscitation prior to ATAAD repair and required ECMO hardly survived [10].

Lin and colleagues [11] reported the use of ECMO in 20 of 162 ATAAD patients (12%) with relatively lower mortality rates (65%). It was also consistent with a current systematic review supporting ECMO use for ATAAD repair [12]. Considering the high incidence of ECMO requirements in their study suggests that they have low threshold for the use of ECMO for left ventricular dysfunction [13], which were treated with IABP in our cohort.

An ECMO registry data from Europe reported 62 of 781 enrolled patients had ATAAD [14]. In-hospital mortality in patients with ATAAD was 74% (63% in non-ATAAD, p = 0.089), which also likely represents different patient indications. In this ECMO registry data, they found neurological events in 34% in ATAAD patients, which were significantly higher than non-ATAAD. Our patients also had high incidence of stroke (64%). In our study, 4 of 11 patients had already presented with coma prior to the ATAAD repair, and many of them had intraoperative hypotension, which likely contributed to the high event rate.

There are concerns with femoral access in patients with peripheral arterial disease or dissection extending to the iliac and/or femoral artery. In this cohort, no cases were observed to have severe enough peripheral arterial disease that we had to consider alternative access. However, axillary access or central access through the graft sidearm is always an alternative option. In patients with dissection extending to the iliac or femoral artery, pulseless leg may be encountered. Sometimes, preoperative computed tomography may not be clear so to which femoral artery would lead to the true lumen in the descending thoracic aorta. It is important to keep in mind that nearly always the pulseless leg is the side of the femoral artery with true lumen, as the limb ischemia is usually caused by compression of the true lumen by the false lumen.

Thus, if the patient presented with right limb ischemia, the right femoral artery should be selected for cannulation. If the limb ischemia is sustained after the central repair, which can be seen in 80% of patients, TEVAR in the descending thoracic aorta, and/or stenting of the affected iliac artery should be considered, and proceed with IABP placement thereafter. In cases of complex dissection, intravascular ultrasound is useful to confirm the true and false lumen and, thus, encouraged to use.

We had one patient who required TEVAR for compressed true lumen in the downstream aorta after the central repair. Compressed true lumen may have difficulties to have the balloon to fully expand, thus, these patients may benefit from TEVAR prior to the IABP initiation to maximize the support of counterpulsation. (Fig. 1)

Fig. 1.

Intra-aortic balloon pump counterpulsation after central repair

While the Impella 5.5 is now available for the management of left ventricular dysfunction, the cases in this study were treated before it became available at our institution. Therefore, our discussion of its potential application in ATAAD patients remains speculative. That said, we believe Impella 5.5 may offer promising support for patients with predominant left ventricular failure. However, several important concerns must be considered in the ATAAD population, including the potential for increased postoperative bleeding and the risk of iatrogenic injury to the dissected aortic arch during device placement. Most critically, the Impella 5.5 does not address right ventricular failure, which limits its utility in patients with biventricular dysfunction. For this reason, we view Impella 5.5 as a potential alternative to IABP, rather than a substitute for ECMO. Our findings suggest that outcomes following ECMO support in ATAAD patients are sobering, and we believe that further investigation is warranted to develop more effective strategies for managing right ventricular failure in this context.

LIMITATIONS.

This study has a few limitations. First, this is a retrospective, nonrandomized, single-center study. The retrospective design of the current analysis restricts the generalizability of our findings, and center-specific biases were independently present. Second, our sample size is very small, which limits the power to find statistical significance. Due to the uncommon nature of this clinical scenario—only 31 cases were encountered over a 20-year period at a single center—it was not feasible to establish an appropriate control group. As such, this study is descriptive in nature, and the absence of a comparative cohort limits the ability to assess the relative risk-benefit profile of mechanical circulatory support strategies in this population. Moreover, this study presents data derived from real-world clinical practice. However, we acknowledge that no formal risk adjustment was performed. The ECMO and IABP groups included patients with heterogeneous clinical conditions—such as cardiogenic shock, malperfusion, and post-cardiopulmonary resuscitation—that are independently associated with poor outcomes. The absence of risk stratification or multivariable analysis limits the ability to distinguish the effects of MCS from the severity of the underlying condition, and this should be considered a limitation of the study.

Third, this study presents real-world outcomes of MCS in the treatment of ATAAD. However, by its nature, the indications for MCS, including IABP and ECMO, were determined at the discretion of individual surgeons. Last, although there were no IABP-specific aortic complications, due to the relatively high operative mortality rate and the critically ill condition of these patients—where even transportation posed a significant risk—postoperative CT imaging was feasible in only 9 patients (1 in the ECMO group and 8 in the IABP group). Moreover, the majority of these scans were either non-contrast or contrast-enhanced CTs performed after weaning from MCS. We are unable to provide sufficient data to evaluate TL or FL status using contrast-enhanced CT imaging performed during active MCS support. Further accumulation of data in these patients is warranted.

Conclusions

In our experience, ECMO support after ATAAD repair was associated with high mortality. While no aortic complications were observed following IABP use in this cohort, these findings are based on a limited number of cases. IABP may represent a potentially viable support option for selected patients recovering from cardiogenic shock after ATAAD repair but its safety should be interpreted with caution.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

ATAAD

Acute type A aortic dissection

CPB

Cardiopulmonary bypass

ECMO

Extracorporeal membrane oxygenation

IABP

Intra-aortic balloon pump

TEE

Transesophageal echocardiogram

Author contributions

AT, YI, HS, CM, HS and AE for conceptualization, review and editing. AT and YI for Writing of original draft. HS and CM for formal analysis, methodology and validation.HS and AE for supervision and review.

Funding

No outside funding was obtained or used for this report.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

Dr. Estrera is on the advisory board of Artivion and a consultant for WL Gore and Terumo Aortic. Dr. Sandhu is also a consultant for WL Gore.

Ethics

The Committee for Protection of Human Subjects, the local institutional review board, approved this study.

Disclosures

Dr. Estrera is on the advisory board of Artivion and a consultant for WL Gore and Terumo Aortic. Dr. Sandhu is also a consultant for WL Gore. The other authors have no conflicts of interest to report.