We read with great interest the article by Pucher et al. regarding the systematic use of heparinization in patients requiring the insertion of an intra-aortic balloon pump (IABP) [1]. The authors reviewed a vast number of published articles and concluded that the decision-making process concerning the use of heparin in patients with IABP conterpulsation should be weighed in the setting of other indications or contraindications rather than being an automatic response.
The IABP was first used to support the failing heart in 1968 [2]. In the 1990s, the introduction of the percutaneous method of insertion broadened the availability and feasibility of IABP use, and nowadays it represents the most usable tool amongst temporary mechanical circulatory support devices for patients suffering from low cardiac output syndrome. However, the use of IABP is not without complications [3], which include bleeding at the site of insertion, local or systemic infection, stoke, aortic or iliac dissection or rupture (occurring in less than 1% but usually fatal) and entrapment of the balloon (associated with balloon rupture and clot formation). Neuropathy and chronic leg pain occur less frequently.
Acute limb ischaemia is the most common complication of IABP use, occurring in 8-42% of cases. More than 30% of patients with limb ischaemia secondary to balloon insertion required surgical intervention [3]. To reduce morbidity of the IABP, heparinization is generally associated with the use of the balloon. Apart from the reduction of the outer diameter of the balloon (11 Fr), another major step to reduce the incidence of vascular complications is the sheathless insertion technique. This technique was recommended by Erdogan et al. [4] in high-risk patients, particularly female patients with peripheral vascular disease. The sheathless insertion technique reduced the incidence of device-related complications to less than 10 % in a study by Nash et al. [5]. Furthermore this modification could be a useful alternative to the use of heparin in patients with a high risk of bleeding.
A prospective clinical trial is required to address the issue of anticoagulation at a higher level of evidence in patients with IABP with or without a sheath.
Conflict of Interest: None declared
References
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