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Undiagnosed aortic dissection in patient with intra‑aortic balloon pump Monish S. Raut, Arun Maheshwari, Manish Sharma1
Departments of Cardiac Anesthesia and 1Cardiology, Dharam Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India
ABSTRACT
Received: 26‑10‑15 Accepted: 19‑05‑16
Videos Available on: www.annals.in Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.185562 Quick Response Code:
60 years old lady presented with chest pain and was admitted in local hospital. Electrocardiogram was suggestive of anterior myocardial ischemia. Patient underwent coronary angiography which revealed severe triple vessles coronary artery disease. As patient was hemodynamically unstable and in cardiogenic shock, intraaortic balloon pump was inserted .IABP augmented diastolic blood pressure was less than unassisted systolic blood pressure despite setting maximum augmentation on IABP machine. Key words: Anterior myocardial ischemia; Cardiogenic shock; Intra‑aortic balloon pump
A 60‑year‑ old female presented with chest pain and was admitted to a local hospital. Electrocardiogram was suggestive of anterior myocardial ischemia. The patient underwent coronary angiography which revealed severe triple vessels coronary artery disease. As the patient was hemodynamically unstable and in cardiogenic shock, intra‑aortic balloon pump (IABP) was inserted percutaneously through the right femoral artery and inotropic infusions through central venous access were started for cardiovascular support. The patient was intubated and referred to our tertiary care center for further management. On evaluation, it was noticed that IABP augmented diastolic blood pressure was less than unassisted systolic blood pressure despite setting of maximum augmentation on IABP machine [Figure 1]. Patient’s recorded coronary angiography study was reexamined. It showed aortic root dilation and right coronary artery (RCA) appeared to have ostial blockage [Figure 2]. Echocardiography showed left ventricular enlargement with poor ventricular function and severe aortic regurgitation. Proximal aorta was seen to be dilated with aneurysmal enlargement and ascending aortic dissecting flap [Figure 3 and Videos 1, 2]. IABP could not augment in the presence of severe aortic regurgitation with aortic dissection.
© 2016 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
IABP was removed as it is detrimental in such scenario. Dissecting aneurysm might be compressing RCA proximally, giving appearance of RCA ostial blockage in angiography [Figure 2]. Definitive diagnosis on computed tomography could not be done as the patient could not survive. IABP is commonly used in patients with multi‑vessel diseases and low ejection fraction to improve coronary blood flow. However, use of IABP may have complications in 20–30% of cases.[1] Complications described are thrombocytopenia, infection, bleeding with aortoiliac artery injury, mesenteric ischemia, renal insufficiency, descending aortic dissection, thromboembolism, and limb ischemia.[1] Address for correspondence: Dr. Monish S. Raut, Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi ‑ 110 060, India. E‑mail: [email protected]
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] Cite this article as: Raut MS, Maheshwari A, Sharma M. Undiagnosed aortic dissection in patient with intra-aortic balloon pump. Ann Card Anaesth 2016;19:549-50.
549
Raut, et al.: IABP in aortic dissection
Figure 1: Intra‑aortic balloon pump augmented diastolic blood pressure was less than unassisted systolic blood pressure despite setting maximum augmentation on intra‑aortic balloon pump machine
Figure 2: Angiography showing dilated aortic root indicated by spread of contrast and right coronary artery ostial blockage
will cause malfunction balloon pump with poor augmentation. However, normally functioning balloon pump within the false channel has also been reported. It may be due to pressure transmission across the intimal flap.[3] Catheter tip consistently overlying lateral aspect of the aorta on chest radiographs can be a clue for suspecting the misplaced IABP, but this may not hold true for malpositioned catheter in the ventral or dorsal aortic wall. Hurwitz and Goodman reported interesting case of malposition of IABP in false lumen but still giving good diastolic augmentation. Malposition was diagnosed on computed tomography done for diagnostic evaluation of pain in the abdomen.[4] In the present case, the patient had ascending aortic dissection with aneurysmal dilation that may be preexisting. Sudden diastolic run‑off into the left ventricle due to severe aortic regurgitation had caused low diastolic augmented pressure in aorta after IABP insertion. It is imperative to do echocardiography before IABP placement. Reasons for improper augmentation of pressure by IABP should always be searched for. Prompt and in time diagnosis of conditions such as aortic dissection and malposition of the catheter can prevent further dreadful complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. REFERENCES
Figure 3: Transesophageal echocardiographic image showing dilated aortic root with dissecting aneurysm and dissecting flap
Ao r t i c d i s s e c t i o n i s s e e n i n 1 – 4 % o f I A B P insertions.[2,3] Catheter insertion into a false lumen
550
1. Vales L, Kanei Y, Ephrem G, Misra D. Intra‑aortic balloon pump use and outcomes with current therapies. J Invasive Cardiol 2011;23:116‑9. 2. Meco M, Gramegna G, Yassini A, Bellisario A, Mazzaro E, Babbini M, et al. Mortality and morbidity from intra‑aortic balloon pumps. Risk analysis. J Cardiovasc Surg (Torino) 2002;43:17‑23. 3. Jacobs LE, Fraifeld M, Kotler MN, Ioli AW. Aortic dissection following intraaortic balloon insertion: Recognition by transesophageal echocardiography. Am Heart J 1992;124:536‑40. 4. Hurwitz LM, Goodman PC. Intraaortic balloon pump location and aortic dissection. AJR Am J Roentgenol 2005;184:1245‑6.
Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3
Undiagnosed aortic dissection in patient with intra‑aortic balloon pump Monish S. Raut, Arun Maheshwari, Manish Sharma1
Departments of Cardiac Anesthesia and 1Cardiology, Dharam Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India
ABSTRACT
Received: 26‑10‑15 Accepted: 19‑05‑16
Videos Available on: www.annals.in Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.185562 Quick Response Code:
60 years old lady presented with chest pain and was admitted in local hospital. Electrocardiogram was suggestive of anterior myocardial ischemia. Patient underwent coronary angiography which revealed severe triple vessles coronary artery disease. As patient was hemodynamically unstable and in cardiogenic shock, intraaortic balloon pump was inserted .IABP augmented diastolic blood pressure was less than unassisted systolic blood pressure despite setting maximum augmentation on IABP machine. Key words: Anterior myocardial ischemia; Cardiogenic shock; Intra‑aortic balloon pump
A 60‑year‑ old female presented with chest pain and was admitted to a local hospital. Electrocardiogram was suggestive of anterior myocardial ischemia. The patient underwent coronary angiography which revealed severe triple vessels coronary artery disease. As the patient was hemodynamically unstable and in cardiogenic shock, intra‑aortic balloon pump (IABP) was inserted percutaneously through the right femoral artery and inotropic infusions through central venous access were started for cardiovascular support. The patient was intubated and referred to our tertiary care center for further management. On evaluation, it was noticed that IABP augmented diastolic blood pressure was less than unassisted systolic blood pressure despite setting of maximum augmentation on IABP machine [Figure 1]. Patient’s recorded coronary angiography study was reexamined. It showed aortic root dilation and right coronary artery (RCA) appeared to have ostial blockage [Figure 2]. Echocardiography showed left ventricular enlargement with poor ventricular function and severe aortic regurgitation. Proximal aorta was seen to be dilated with aneurysmal enlargement and ascending aortic dissecting flap [Figure 3 and Videos 1, 2]. IABP could not augment in the presence of severe aortic regurgitation with aortic dissection.
© 2016 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
IABP was removed as it is detrimental in such scenario. Dissecting aneurysm might be compressing RCA proximally, giving appearance of RCA ostial blockage in angiography [Figure 2]. Definitive diagnosis on computed tomography could not be done as the patient could not survive. IABP is commonly used in patients with multi‑vessel diseases and low ejection fraction to improve coronary blood flow. However, use of IABP may have complications in 20–30% of cases.[1] Complications described are thrombocytopenia, infection, bleeding with aortoiliac artery injury, mesenteric ischemia, renal insufficiency, descending aortic dissection, thromboembolism, and limb ischemia.[1] Address for correspondence: Dr. Monish S. Raut, Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi ‑ 110 060, India. E‑mail: [email protected]
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] Cite this article as: Raut MS, Maheshwari A, Sharma M. Undiagnosed aortic dissection in patient with intra-aortic balloon pump. Ann Card Anaesth 2016;19:549-50.
549
Raut, et al.: IABP in aortic dissection
Figure 1: Intra‑aortic balloon pump augmented diastolic blood pressure was less than unassisted systolic blood pressure despite setting maximum augmentation on intra‑aortic balloon pump machine
Figure 2: Angiography showing dilated aortic root indicated by spread of contrast and right coronary artery ostial blockage
will cause malfunction balloon pump with poor augmentation. However, normally functioning balloon pump within the false channel has also been reported. It may be due to pressure transmission across the intimal flap.[3] Catheter tip consistently overlying lateral aspect of the aorta on chest radiographs can be a clue for suspecting the misplaced IABP, but this may not hold true for malpositioned catheter in the ventral or dorsal aortic wall. Hurwitz and Goodman reported interesting case of malposition of IABP in false lumen but still giving good diastolic augmentation. Malposition was diagnosed on computed tomography done for diagnostic evaluation of pain in the abdomen.[4] In the present case, the patient had ascending aortic dissection with aneurysmal dilation that may be preexisting. Sudden diastolic run‑off into the left ventricle due to severe aortic regurgitation had caused low diastolic augmented pressure in aorta after IABP insertion. It is imperative to do echocardiography before IABP placement. Reasons for improper augmentation of pressure by IABP should always be searched for. Prompt and in time diagnosis of conditions such as aortic dissection and malposition of the catheter can prevent further dreadful complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. REFERENCES
Figure 3: Transesophageal echocardiographic image showing dilated aortic root with dissecting aneurysm and dissecting flap
Ao r t i c d i s s e c t i o n i s s e e n i n 1 – 4 % o f I A B P insertions.[2,3] Catheter insertion into a false lumen
550
1. Vales L, Kanei Y, Ephrem G, Misra D. Intra‑aortic balloon pump use and outcomes with current therapies. J Invasive Cardiol 2011;23:116‑9. 2. Meco M, Gramegna G, Yassini A, Bellisario A, Mazzaro E, Babbini M, et al. Mortality and morbidity from intra‑aortic balloon pumps. Risk analysis. J Cardiovasc Surg (Torino) 2002;43:17‑23. 3. Jacobs LE, Fraifeld M, Kotler MN, Ioli AW. Aortic dissection following intraaortic balloon insertion: Recognition by transesophageal echocardiography. Am Heart J 1992;124:536‑40. 4. Hurwitz LM, Goodman PC. Intraaortic balloon pump location and aortic dissection. AJR Am J Roentgenol 2005;184:1245‑6.
Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3
