lntraaortic
Counterpulsation
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
ERIC
A. HYSON,1
CARL
Balloon: E. RAVIN,
MICHAEL
The intraaortic counterpulsation balloon is being used with increasing frequency in the setting of cardiogenic shock and/or high risk cardiac surgery. The radiologist should be aware of the normal function of this cardiac assist device, as well as its potential complications. The principal complications apparent on the plain chest radiograph are related to improper positioning of the balloon catheter.
for
J. KELLEY,
and
should
moving distally, the left ventricle
rupture
myocardial
the
in the
immediate
postoperative
Function
and
[12,
1
reprint
Am
January
All authors: requests
J Roentgenol
6. 1977.
Department to
C
E
accepted
February Radiology,
June
1977
itself.
work
and
cardiac
pumping
oxygen the re-
function
is
[4].
be positioned
artery
feasible
[7];
occlusion
Axillary
artery
however,
thoracic
aorta
surgery,
if difficulty
Most
the
through
graft
placed
[171. Ideally, just
distal
to the
at the level of the aortic
of the renal insertion
balloon
the
has
can
arteries not
by the
yet
proved
be positioned
ascending
in placement
radiographically
from
improper
an excessive
aorta through
in the
at the
time
of
atherosclerotic
Such placement, however, for removal at the completion
of the
left
with of
131.
to
the
tently
can
artery dissection
impaction
of the
subclavian
artery
be advanced
into
1. - Partially inflated Medical Products.
19]
(fig.
also
been
balloon
catheter
re-
Insertion
of
in obstruction 3).
Aortic
reported
tear sec-
at the
origin
The
balloon
may
inadver-
proximal
aortic
arch,
thereby
preclude in the
intraaortic Everett.
result
[18,
[181. the
complications
balloon.
has
risk of embolism disease involving
its distal branches may the appropriate position
Fig Avco
IACB of the
of catheter
subclavian
subsequent
ondary
apparent positioning
length
increasing the Arteriosclerotic
23,
should
subclavian
left
or intermittent
balloon
suIt
to the cerebral vessels. the abdominal aorta and the balloon ever reaching thoracic aorta (fig. 4). It is
balloon (Avco Tri’Segment Mass ( surrounding distal
Balloon. portion
of catheter
1977. Yale
University
School
Ravin
128:915-918,
balloon
of the
aortic
oxygen delivery to decreasing oxygen
overall
balloon
of
Complications
Placement
of Diagnostic
systole,
intraaortic
Deflation
column
the afterload against its stroke volume, and
ventricular
femoral arteries is anticipated. requires limited thoracotomy of balloon pumping.
Several models of intraaortic balloons are presently in use, but their basic principles of cardiac assistance are essentially the same [8, 14, 151. All consist of a roughly cylindrical or fusiform inflatable bag about 26 cm long surrounding a catheter [161 (fig. 1). The balloon is inflated with about 40 cm3 of gas (depending on balloon size) during diastole and is forcibly deflated during systole (fig. 2). Inflation-deflation timing is linked electrically to the electrocardiogram. Inflation during diastole increases diastolic blood pressue in the proximal aorta, thereby increasing perfusion of the coronary arteries which takes place primarily during diastole. Improved coronary artery perfusion increases oxygen delivery to the myocardium Received
decreasing must eject left
action.
the
knob. This position results in maximum augmentation of coronary artery flow while minimizing the risk of embolus to the cerebral vessels. occlusion of the left subclavian
infarction
period
starts
by increasing diastole and
during
tip of the
origin
has also been managed with the balloon [9]. Patients in cardiogenic shock following myocardial infarction or patients with unstable angina may be stabilized using the IACB, allowing performance of coronary angiography prior to coronary artery bypass surgery [4, 10, 1 ii. In high risk patients undergoing coronary artery and valvular surgery, balloon pumping can be used preoperatively, allowing the myocardium to better tolerate the stress of surgery [12]. Finally, the intraaortic balloon can provide an intermediate level of cardiac assistance in patients who otherwise could not be weaned from cardiopulmonary bypass
pumping
systole
Thus during by
CURTIS
The IACB is inserted through a Dacron end-to-side to the common femoral artery
Use
following
during
diminishing
improved
McB.
myocardial
blood which
artery,
septal
improve
quirements
Considerations
ANNE
balloon
requirement. myocardium
The IACB was originally proposed to improve cardiac function in the setting of cardiogenic shock [1, 21, and this continues to be a major indication for its use [3-8]. Cardiac failure related to acute mitral insufficiency or to ventricular
AND
of the
thereby
Since the initial description in 1962 [1, 2], the intraaortic counterpulsation balloon (IACB) has gained increasing popularity as a method for improving cardiac function in critically ill patients. In order to detect potential complications related to use of this device, the radiologist should be familiar with its normal function and placement. Indications
Radiographic
915
of
Medicine,
333
Cedar
Street,
New
Haven,
Connecticut
06510
Address
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
916
HYSON
Fig. (aortic
Fig into
2.-A. valve
left
Chest closed)
3.-Chest subclavian
film showing
film
showing inflated
showing IACB artery. (Reprinted
appearance balloon
of
IACB
visualized
extending above from [19))
in systole as radiolucent
level
of aortic
(note
open cylinder
knob
ET AL.
aortic (arrows)
valve).
Deflated
projected
Fig. 4.-Radiograph vessels showing level. Distal tip of diaphragm.
balloon in lumen
not
visualized.
of descending
B. Chest
film
during
diastole
aorta.
of patient with markedly catheter following tortuous of catheter could not be
tortuous aorta and great route and kinking at L2 advanced beyond level
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
INTRAAORTIC
‘i
5,
COUNTERPULSATION BALLOON 917
HYSON
918
rupture
secondary
patient
[7].
either
to
improper
Although
carbon
insertion
balloon
dioxide
or
helium
for
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
oxide has the theoretical advantage in blood in the event of gas escape.
doses
of
1 -3
occurred
pumps
are inflation,
of Helium
in one
available
using
carbon
di-
higher solubility in intravascular
has been shown to be rapidly fatal [21 1 However, its better flow rate allows for more rapid balloon inflation and deflation. Because of the potential dangers of balloon rupture, howin canine
ever,
mI/kg
experiments
carbon
.
dioxide
is usually
chosen
as the
inflating
gas.
Theoretically, intravascular gas might be visible on plain films in the event of gas rupture. Other intraaortic balloon complications have been reported which would not be apparent on routine chest radiographs. These include wound infections at the site of balloon insertion, hemolysis, moderate decrease in platelet count, and arterial insufficiency of the catheterized leg [3, 4, 7, 8, 13]. Thromboembolic episodes involving the aorta or renal, celiac, or mesenteric arteries are decreased by heparinization and maintenance in the pumping rather than stationary mode
of the balloon [4, 7, 1 2, 13,
22, 23]. The incidence of ventricular rupture in balloontreated postmyocardial infarction patients is somewhat increased, probably secondary to prolongation of survival with a further evolution of large infarcts [3, 71.
ET AL.
pulsation in cardiogenic shock. NEngIJ Med 288:979-984, 1973 8. Weber KT, Janicki JS: Intraaortic balloon counterpulsation. Ann Thorac Surg 17:602-636. 1974 9, Gold HK, Leinbach RC, Sanders CA, Buckley MJ, Mundth ED, Austen WG: lntraaortic balloon pumping for ventricular septal
11
.
.
Moulopoulos SD, Topaz assistance to the circulation Trans Am Soc Artif Intern
2. Moulopoulos ing
(with
tance 1962
SD. Topaz 5, Kolff WJ: Diastolic
carbon
to the
3. Butner
failing
AN,
Sherman
dioxide)
in the
circulation. JS,
Krakauer
JL
Jr.
Dresdale
aorta-a Am
balloon
Heart
A,
Kantrowitz
assis-
63:669-675,
J
Tjonneland A:
Clinical
results
for cardiogenic
5. Kantrowitz
A,
of intraaortic
Krakauer
Wolff Oldham
G,
JS,
D: Phase-shift
pumping
and
46:465-477, Rosenbaum A,
1972 Butner
balloon
in medically
pumping
AN:
Mechanical
shock, 5,
Wilner
Krakauer
intraaortic H,
J, Rubenfire
Summers
M,
Fleming
A: Intra-aortic
Lesch
M,
P. Noon balloon
counter-
G,
J
SO: lntra-aortic
Land RE, monitoring
Mundth
ED,
in
Thorac
Buckley
patients
MJ,
undergoing
Cardiovasc
balloon
Surg
C/in
Civetta JM: and assistance
J Roentgenol
and
62:
Surg
pumping
North
Am
The appearance devices on chest
1 13:522-526,
for
low cardiac
55:101-106,
1975
of cardiovascular roentgenograms.
1971
subclavian
artery
during
intraaortic
balloon
pumping.
65:543-546, 1973 19. Ravin CE, Putman CE, McLoud TC: Hazards of the intensive care unit. Am J Roentgenol 126:423-431, 1976 20. Pace P. Tilney N, Couch N, Lesch M: Peripheral arterial Cardiovasc
complications
AN,
1968 D,
device.
syndromes.
54.
S.
Furman
Escher
DJ:
Surgery 22.
2:13,
EF,
23. Madras
of
PN,
AE
Jr: from
62:950-956, Laird JD, latridis
WG: Trans
(abstr.).
R.
intraaortic
McMullen balloon
M. rupture.
1971
Murphy
Surg
Austen
pumping.
Rosenbaum
sequelae
thrombosis
Cardiovasc
counterpulsation
1976
R.
Lethal
in preventing
1969
suppl.
balloon
Vijaynagar
69:121-129.
Bernstein
MJ,
Surg
of intraaortic
Circulation
in
acute
17. Kantrowitz A, Phillips SJ. Butner AN. Tj#{248}nneland S. HaIler JD: Technique of femoral artery cannulation for phase-shift balloon pumping. J Thorac Cardiovasc Surg 56:219-220, 1968 18. O’Rourke MF, Shepherd KM: Protection of the aortic arch
21.
assistance
97:1000-1004,
Arch Surg G. Mueller
N. Killip T, Kantrowitz
cardiac
complicating
1971
1 5. Burman
surgery
cardiogenic shock, Arch Surg 99:739-743, 1969 A, Tjdnneland 5, Krakauer JS, Phillips SJ, Freed
refractory 6. Kantrowitz PS, Butner cardiogenic 7. Scheidt
Circulation
shock.
Freed PS, Jaron
balloon
RE,
counterpulsation
assist
577-591.
J Thorac
balloon pumping in cardiogenic shock: results in 29 patients, Surg Forum 20:199-200, 1969 4. Dunkman WB, Leinbach RC, Buckley MJ, Mundth ED, Kantrowitz AR, Austen WG, Sanders CA: Clinical and hemo-
regurgitation
Dinsmore
balloon
cardiac
S. trial
mitral
cardiac operations. Ann Thorac Surg 20:652-660, 1975 13. Berger RL. Saini VK, Ryan TJ. Sokol DM, Keefe JF: Intraaortic balloon assist for postcardiotomy cardiogenic shock. J Thorac Cardiovasc Surg 66:906-91 5, 1973 14. Bregman D, Goetz RH: Clinical experience with a new
Am
of phase-shift
dynamic
RC,
aortic
16.
pump-
mechanical
Rosenbaum DT,
Leinbach
output
SR. Kolff WJ: Extracorporeal and intraaortic balloon pumping. Organs 8:85-89, 1962
or
Dunkman WB, Austen WG, Sanders CA: Selective coronary and left ventricular cineangiography during intraaortic balloon pumping for cardiogenic shock. Circulation 45: 845-852. 1972 1 2, Cleveland JC, Lefemine AA, Madoff I, Black H, Amato J, Sewell DH. Rheinlander HF, Cleveland RJ: The role of intra-
REFERENCES 1
defect
myocardial infarction. Circulation 47:1191-1196, 1973 10. Gold HK, Leinbach RC, Sanders CA, Buckely MJ, Mundth ED, Austen WG: Intraaortic balloon pumping for control of recurrent myocardial ischemia. Circulation 47 : 1 197-1203, 1973
Am
Effects
of
Soc
Art/f
The
importance
intraaortic
1971 E, Kantrowitz prolonged Intern
of
AR,
intraaortic Organs
pulsation J Thorac
balloons.
Buckley balloon
15:400-405,
Counterpulsation
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
ERIC
A. HYSON,1
CARL
Balloon: E. RAVIN,
MICHAEL
The intraaortic counterpulsation balloon is being used with increasing frequency in the setting of cardiogenic shock and/or high risk cardiac surgery. The radiologist should be aware of the normal function of this cardiac assist device, as well as its potential complications. The principal complications apparent on the plain chest radiograph are related to improper positioning of the balloon catheter.
for
J. KELLEY,
and
should
moving distally, the left ventricle
rupture
myocardial
the
in the
immediate
postoperative
Function
and
[12,
1
reprint
Am
January
All authors: requests
J Roentgenol
6. 1977.
Department to
C
E
accepted
February Radiology,
June
1977
itself.
work
and
cardiac
pumping
oxygen the re-
function
is
[4].
be positioned
artery
feasible
[7];
occlusion
Axillary
artery
however,
thoracic
aorta
surgery,
if difficulty
Most
the
through
graft
placed
[171. Ideally, just
distal
to the
at the level of the aortic
of the renal insertion
balloon
the
has
can
arteries not
by the
yet
proved
be positioned
ascending
in placement
radiographically
from
improper
an excessive
aorta through
in the
at the
time
of
atherosclerotic
Such placement, however, for removal at the completion
of the
left
with of
131.
to
the
tently
can
artery dissection
impaction
of the
subclavian
artery
be advanced
into
1. - Partially inflated Medical Products.
19]
(fig.
also
been
balloon
catheter
re-
Insertion
of
in obstruction 3).
Aortic
reported
tear sec-
at the
origin
The
balloon
may
inadver-
proximal
aortic
arch,
thereby
preclude in the
intraaortic Everett.
result
[18,
[181. the
complications
balloon.
has
risk of embolism disease involving
its distal branches may the appropriate position
Fig Avco
IACB of the
of catheter
subclavian
subsequent
ondary
apparent positioning
length
increasing the Arteriosclerotic
23,
should
subclavian
left
or intermittent
balloon
suIt
to the cerebral vessels. the abdominal aorta and the balloon ever reaching thoracic aorta (fig. 4). It is
balloon (Avco Tri’Segment Mass ( surrounding distal
Balloon. portion
of catheter
1977. Yale
University
School
Ravin
128:915-918,
balloon
of the
aortic
oxygen delivery to decreasing oxygen
overall
balloon
of
Complications
Placement
of Diagnostic
systole,
intraaortic
Deflation
column
the afterload against its stroke volume, and
ventricular
femoral arteries is anticipated. requires limited thoracotomy of balloon pumping.
Several models of intraaortic balloons are presently in use, but their basic principles of cardiac assistance are essentially the same [8, 14, 151. All consist of a roughly cylindrical or fusiform inflatable bag about 26 cm long surrounding a catheter [161 (fig. 1). The balloon is inflated with about 40 cm3 of gas (depending on balloon size) during diastole and is forcibly deflated during systole (fig. 2). Inflation-deflation timing is linked electrically to the electrocardiogram. Inflation during diastole increases diastolic blood pressue in the proximal aorta, thereby increasing perfusion of the coronary arteries which takes place primarily during diastole. Improved coronary artery perfusion increases oxygen delivery to the myocardium Received
decreasing must eject left
action.
the
knob. This position results in maximum augmentation of coronary artery flow while minimizing the risk of embolus to the cerebral vessels. occlusion of the left subclavian
infarction
period
starts
by increasing diastole and
during
tip of the
origin
has also been managed with the balloon [9]. Patients in cardiogenic shock following myocardial infarction or patients with unstable angina may be stabilized using the IACB, allowing performance of coronary angiography prior to coronary artery bypass surgery [4, 10, 1 ii. In high risk patients undergoing coronary artery and valvular surgery, balloon pumping can be used preoperatively, allowing the myocardium to better tolerate the stress of surgery [12]. Finally, the intraaortic balloon can provide an intermediate level of cardiac assistance in patients who otherwise could not be weaned from cardiopulmonary bypass
pumping
systole
Thus during by
CURTIS
The IACB is inserted through a Dacron end-to-side to the common femoral artery
Use
following
during
diminishing
improved
McB.
myocardial
blood which
artery,
septal
improve
quirements
Considerations
ANNE
balloon
requirement. myocardium
The IACB was originally proposed to improve cardiac function in the setting of cardiogenic shock [1, 21, and this continues to be a major indication for its use [3-8]. Cardiac failure related to acute mitral insufficiency or to ventricular
AND
of the
thereby
Since the initial description in 1962 [1, 2], the intraaortic counterpulsation balloon (IACB) has gained increasing popularity as a method for improving cardiac function in critically ill patients. In order to detect potential complications related to use of this device, the radiologist should be familiar with its normal function and placement. Indications
Radiographic
915
of
Medicine,
333
Cedar
Street,
New
Haven,
Connecticut
06510
Address
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
916
HYSON
Fig. (aortic
Fig into
2.-A. valve
left
Chest closed)
3.-Chest subclavian
film showing
film
showing inflated
showing IACB artery. (Reprinted
appearance balloon
of
IACB
visualized
extending above from [19))
in systole as radiolucent
level
of aortic
(note
open cylinder
knob
ET AL.
aortic (arrows)
valve).
Deflated
projected
Fig. 4.-Radiograph vessels showing level. Distal tip of diaphragm.
balloon in lumen
not
visualized.
of descending
B. Chest
film
during
diastole
aorta.
of patient with markedly catheter following tortuous of catheter could not be
tortuous aorta and great route and kinking at L2 advanced beyond level
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
INTRAAORTIC
‘i
5,
COUNTERPULSATION BALLOON 917
HYSON
918
rupture
secondary
patient
[7].
either
to
improper
Although
carbon
insertion
balloon
dioxide
or
helium
for
Downloaded from www.ajronline.org by 190.106.61.39 on 11/19/15 from IP address 190.106.61.39. Copyright ARRS. For personal use only; all rights reserved
oxide has the theoretical advantage in blood in the event of gas escape.
doses
of
1 -3
occurred
pumps
are inflation,
of Helium
in one
available
using
carbon
di-
higher solubility in intravascular
has been shown to be rapidly fatal [21 1 However, its better flow rate allows for more rapid balloon inflation and deflation. Because of the potential dangers of balloon rupture, howin canine
ever,
mI/kg
experiments
carbon
.
dioxide
is usually
chosen
as the
inflating
gas.
Theoretically, intravascular gas might be visible on plain films in the event of gas rupture. Other intraaortic balloon complications have been reported which would not be apparent on routine chest radiographs. These include wound infections at the site of balloon insertion, hemolysis, moderate decrease in platelet count, and arterial insufficiency of the catheterized leg [3, 4, 7, 8, 13]. Thromboembolic episodes involving the aorta or renal, celiac, or mesenteric arteries are decreased by heparinization and maintenance in the pumping rather than stationary mode
of the balloon [4, 7, 1 2, 13,
22, 23]. The incidence of ventricular rupture in balloontreated postmyocardial infarction patients is somewhat increased, probably secondary to prolongation of survival with a further evolution of large infarcts [3, 71.
ET AL.
pulsation in cardiogenic shock. NEngIJ Med 288:979-984, 1973 8. Weber KT, Janicki JS: Intraaortic balloon counterpulsation. Ann Thorac Surg 17:602-636. 1974 9, Gold HK, Leinbach RC, Sanders CA, Buckley MJ, Mundth ED, Austen WG: lntraaortic balloon pumping for ventricular septal
11
.
.
Moulopoulos SD, Topaz assistance to the circulation Trans Am Soc Artif Intern
2. Moulopoulos ing
(with
tance 1962
SD. Topaz 5, Kolff WJ: Diastolic
carbon
to the
3. Butner
failing
AN,
Sherman
dioxide)
in the
circulation. JS,
Krakauer
JL
Jr.
Dresdale
aorta-a Am
balloon
Heart
A,
Kantrowitz
assis-
63:669-675,
J
Tjonneland A:
Clinical
results
for cardiogenic
5. Kantrowitz
A,
of intraaortic
Krakauer
Wolff Oldham
G,
JS,
D: Phase-shift
pumping
and
46:465-477, Rosenbaum A,
1972 Butner
balloon
in medically
pumping
AN:
Mechanical
shock, 5,
Wilner
Krakauer
intraaortic H,
J, Rubenfire
Summers
M,
Fleming
A: Intra-aortic
Lesch
M,
P. Noon balloon
counter-
G,
J
SO: lntra-aortic
Land RE, monitoring
Mundth
ED,
in
Thorac
Buckley
patients
MJ,
undergoing
Cardiovasc
balloon
Surg
C/in
Civetta JM: and assistance
J Roentgenol
and
62:
Surg
pumping
North
Am
The appearance devices on chest
1 13:522-526,
for
low cardiac
55:101-106,
1975
of cardiovascular roentgenograms.
1971
subclavian
artery
during
intraaortic
balloon
pumping.
65:543-546, 1973 19. Ravin CE, Putman CE, McLoud TC: Hazards of the intensive care unit. Am J Roentgenol 126:423-431, 1976 20. Pace P. Tilney N, Couch N, Lesch M: Peripheral arterial Cardiovasc
complications
AN,
1968 D,
device.
syndromes.
54.
S.
Furman
Escher
DJ:
Surgery 22.
2:13,
EF,
23. Madras
of
PN,
AE
Jr: from
62:950-956, Laird JD, latridis
WG: Trans
(abstr.).
R.
intraaortic
McMullen balloon
M. rupture.
1971
Murphy
Surg
Austen
pumping.
Rosenbaum
sequelae
thrombosis
Cardiovasc
counterpulsation
1976
R.
Lethal
in preventing
1969
suppl.
balloon
Vijaynagar
69:121-129.
Bernstein
MJ,
Surg
of intraaortic
Circulation
in
acute
17. Kantrowitz A, Phillips SJ. Butner AN. Tj#{248}nneland S. HaIler JD: Technique of femoral artery cannulation for phase-shift balloon pumping. J Thorac Cardiovasc Surg 56:219-220, 1968 18. O’Rourke MF, Shepherd KM: Protection of the aortic arch
21.
assistance
97:1000-1004,
Arch Surg G. Mueller
N. Killip T, Kantrowitz
cardiac
complicating
1971
1 5. Burman
surgery
cardiogenic shock, Arch Surg 99:739-743, 1969 A, Tjdnneland 5, Krakauer JS, Phillips SJ, Freed
refractory 6. Kantrowitz PS, Butner cardiogenic 7. Scheidt
Circulation
shock.
Freed PS, Jaron
balloon
RE,
counterpulsation
assist
577-591.
J Thorac
balloon pumping in cardiogenic shock: results in 29 patients, Surg Forum 20:199-200, 1969 4. Dunkman WB, Leinbach RC, Buckley MJ, Mundth ED, Kantrowitz AR, Austen WG, Sanders CA: Clinical and hemo-
regurgitation
Dinsmore
balloon
cardiac
S. trial
mitral
cardiac operations. Ann Thorac Surg 20:652-660, 1975 13. Berger RL. Saini VK, Ryan TJ. Sokol DM, Keefe JF: Intraaortic balloon assist for postcardiotomy cardiogenic shock. J Thorac Cardiovasc Surg 66:906-91 5, 1973 14. Bregman D, Goetz RH: Clinical experience with a new
Am
of phase-shift
dynamic
RC,
aortic
16.
pump-
mechanical
Rosenbaum DT,
Leinbach
output
SR. Kolff WJ: Extracorporeal and intraaortic balloon pumping. Organs 8:85-89, 1962
or
Dunkman WB, Austen WG, Sanders CA: Selective coronary and left ventricular cineangiography during intraaortic balloon pumping for cardiogenic shock. Circulation 45: 845-852. 1972 1 2, Cleveland JC, Lefemine AA, Madoff I, Black H, Amato J, Sewell DH. Rheinlander HF, Cleveland RJ: The role of intra-
REFERENCES 1
defect
myocardial infarction. Circulation 47:1191-1196, 1973 10. Gold HK, Leinbach RC, Sanders CA, Buckely MJ, Mundth ED, Austen WG: Intraaortic balloon pumping for control of recurrent myocardial ischemia. Circulation 47 : 1 197-1203, 1973
Am
Effects
of
Soc
Art/f
The
importance
intraaortic
1971 E, Kantrowitz prolonged Intern
of
AR,
intraaortic Organs
pulsation J Thorac
balloons.
Buckley balloon
15:400-405,
