Anaesth Intensive Care 2015 | 43:1

Complications of intra-aortic balloon pump use: does the final

position of the IABP tip matter?
M. Siriwardena*, A. Pilbrow†, C. Frampton‡, S. M. MacDonald§, G. T. Wilkins**, A. M. Richards††

Summary
We report results of a retrospective review of intra-aortic balloon pump (IABP) use in two Australasian centres and evaluate
the effect of final IABP tip position on outcome. Indications for counterpulsation, patient demographics and in-hospital
outcomes and complications were retrospectively collected. The chest X-ray reports provided the ‘final’ position of the IABP
tip. The position was defined as acceptable (tip was seen just below the aortic arch, at T2–T5 vertebrae), malpositioned
(tip >5 cm below aortic arch or at T5–T6) or severely malpositioned (tip >10 cm below aortic arch or at T7 or below). Major
complications were considered a composite of death secondary to IABP, major limb ischaemia, major IABP malfunction,
balloon rupture or haemorrhage, severe renal dysfunction (rise in creatinine >200 µmol/l), stroke and mesenteric ischaemia.
Six hundred and forty-five cases were reviewed. The overall major complication rate was 26.2% and 24.3%. Severe renal
impairment was the most common complication (16.6%), and second, severe catheter dysfunction (5.4%). Final IABP
position was acceptable in 39.9%, malpositioned in 11.1%, severely malpositioned in 6.7% and unavailable for 42.4%. Logistic
regression analysis showed IABP tip malposition (compared with satisfactory position odds ratio=3.9 [95% confidence
interval=2.0-7.6, P <0.001] and severely malpositioned odds ratio=13.0 [95% confidence interval=5.3–31.7, P <0.001]) were
associated with major complications more than the presence of shock (odds ratio=3.8, confidence interval 2.1–6.8 P <0.001).
The acceptance of a less than ideal final position was highly predictive of morbidity directly related to IABP device therapy.

Key Words: counterpulsation, intra-aortic balloon pump, mechanical support, cardiogenic shock

The intra-aortic balloon pump (IABP) is currently the most
widely used circulatory assist device for the treatment of
cardiogenic shock, a condition which remains associated
with high mortality rates1,2. The potential for benefit of
counterpulsation in the setting of cardiogenic shock has
been demonstrated previously3–5. A recent randomised con-
trolled trial has questioned the benefit of IABP use in the
setting of acute myocardial infarction (AMI) treated with pri-
mary percutaneous intervention (PCI) as opposed to throm-
bolytics6. It is of interest to note however, that when IABPs
are compared to more aggressive forms of mechanical sup-
port such as percutaneous left ventricular assist devices,
there is still no firm evidence of improved survival rates
despite the increased cost and complexity of treatment with
percutaneous left ventricular assist devices7,8.
For the last five decades, the indications for IABP use have
expanded as confidence in its safety has increased. There
has been a move from reserving IABP use for patients in
* MBChB, PhD, FRACP, Cardiology and Intensive Care, Christchurch School of Medicine,
University of Otago, New Zealand
† PhD, Health Research Council Sir Charles Hercus Research Fellow, Christchurch
School of Medicine, University of Otago, New Zealand
‡ PhD, Biostatistician, Christchurch School of Medicine, University of Otago, New
Zealand
§ MD, Consultant Thoracic Radiologist, Department of Radiology, Christchurch Public
Hospital, Christchurch, New Zealand
** MD, FRACP, Cardiologist, Department of Cardiology, Dunedin Public Hospital,
Dunedin, New Zealand
†† MD, PhD, DSc, Cardiologist, Department of Cardiology, Christchurch School of
Medicine, University of Otago, New Zealand
Address for correspondence: Dr Maithri Siriwardena. Email: maithri.siriwardena@gmail.com
Accepted for publication on September 16, 2014
extremis towards use as a prophylactic measure in both
high-risk PCI and high-risk cardiac surgery9–13. However, the
potential for complications still exists despite advances in
catheter design and increasing sophistication of consoles.
Current theories regarding counterpulsation-related com-
plications are often based on results from the Benchmark
Registry, a large, highly regarded, multicentre registry14. This
registry has identified the presence of peripheral vascular
disease, female sex, body surface area <1.65m2 and age
>75 years as significant, independent predictors of major
complications following IABP therapy. Subsequent studies
have confirmed these findings and, in addition, identified
reduced left ventricular ejection fraction as an additional
risk factor15–18.
In this study, we elected to look at the association of final
IABP tip position with the occurrence of major complica-
tions including renal dysfunction. The possibility of IABP
tip migration exists in practice but the potential may be
underestimated. There is currently no standardised protocol
suggesting the frequency with which the IABP tip position
should be reassessed post placement.
Methods
Patients who received IABP device therapy from 1998 to
2008 were identified from records held by the perfusion-
ists and cardiology technicians of Christchurch and Dunedin
Hospitals and cross-referenced with the internal coding sys-
tem at each hospital. Indications for counterpulsation, patient

66
Anaesth Intensive Care 2015 | 43:1
Figure 1: A=Acceptable position—just below the aortic
arch, at T2–T5, or at bifurcation of the trachea (n=251).
B=Malpositioned—at T5-T6, greater than 5 cm below the
aortic arch (n=72). C=Severely malpositioned—at T7 or
below, greater than 10 cm below aortic arch (n=36).
demographics, clinical characteristics, in-hospital outcomes
and complications were documented retrospectively from the
individual patient medical records by a single investigator. An
ethics application was made to the Upper South B Regional
Ethics Committee, which confirmed that no formal ethics
approval was required for this retrospective review.
Christchurch and Dunedin Hospitals are tertiary referral
centres and teaching hospitals that provide on-site cardiac
Does the final position of the IABP tip matter?
surgery. All devices in Christchurch and Dunedin used dur-
ing that period were Datascope (Datascope Corp., Maquet
Getinge Group, Fairfield, NJ, USA), with eight French calibre
catheters.
Major complications relating to IABP were divided into two
categories. Major complications group 1 was as reported in
the Benchmark Registry so that direct comparisons could be
made. This category was a composite of death secondary to
counterpulsation, major limb ischaemia (defined as requir-
ing premature discontinuation of counterpulsation or the
need for surgical intervention in the form of embolectomy
or amputation), balloon malfunction requiring premature
removal, balloon rupture and haemorrhage secondary to the
IABP insertion requiring blood transfusion. Major complica-
tion group 2 was a composite endpoint of major complication
group 1 and, in addition, severe renal dysfunction (defined
as a rise in plasma creatinine of >200 μmol/l from baseline),
stroke and either proven or suspected mesenteric ischaemia.
The chest radiograph reports provided the ‘final’ position
of the radio-opaque tip. The position was defined as accept-
able, malpositioned, severely malpositioned or unavailable.
An acceptable IABP position was recorded when the tip
was seen just below the aortic arch, at T2–T5 if referenced
according to the thoracic vertebral bodies, or at the bifur-
cation of the carina. A malpositioned IABP was defined
as the tip being greater than 5 cm below aortic arch or at
T5–T6. A severely malpositioned IABP was defined as the tip
being greater than 10 cm below aortic arch or referenced
at T7 or below (Figure 1). If the IABP tip was repositioned
from being malpositioned or severely malpositioned to an
acceptable position within six hours, the position was taken
as acceptable. The IABP position was recorded as unavail-
able when the tip position was not mentioned on the chest
radiograph report or in patients for whom no chest radio-
graph was taken after IABP placement. The chest X-rays
were reported by experienced consultant radiologists. To
ensure the accuracy of the radiologist’s reports, all digitally
stored chest radiographs were reviewed.
Shock, usually cardiogenic, at the time of IABP insertion
was defined as a clearly documented sustained systolic blood
pressure below 80 mmHg. A record of inotrope and/or vaso-
pressor use was noted.
Statistical analysis
The relationship between major complications and clinical
setting (cardiology, preoperative, intra- or postoperative),
method of IABP insertion (fluoroscopic guidance, insertion
doctor), duration of use, presence of shock, mortality and
hospital where IABP insertion was performed were analysed
using chi-square and Fisher exact tests. Associations between
major complications and age and risk scores were analysed
with analysis of variance.
Factors significantly associated with major complications
were included in a multivariate, stepwise forward, condi-
tional logistic regression. The factors interrogated included
67
 M. Siriwardena et al Anaesth Intensive Care 2015 | 43:1

the presence of peripheral vascular disease, female sex,
age, hypertension and ejection fraction <35%. These factors
have previously been identified as predictors of complica-
tion14–18. In addition, the presence of shock at the time of
insertion, the clinical setting in which the IABP was placed,
whether fluoroscopy was used during the insertion, the
duration of counterpulsation use, and whether the final
chest X-ray position was acceptable were included.
Once the significance of each factor was determined
with this model, the odds ratios (OR) and 95% confidence
intervals (CI) were determined by an enter or base model.
The IABP tip position groups were entered as four separate
groups consisting of acceptable, unavailable, malpositioned
or severely malpositioned.
ORs reported for malpositioned IABPs are relative to the
chance of a complication if the chest radiograph showed
an acceptable position. All statistical analyses were per-
formed using SPSS, version 19 (IBM, Armonk, NY, USA), and
a P-value of <0.05 was taken to indicate statistical signifi-
cance.
Results
Patient characteristics
Six hundred and seventy-three patients who received IABP
device therapy were identified and medical records were
available for 645 (95.8%). The mean age of patients (n=645)
was 66 years (standard deviation ± 12 years) and 432 (66.9%)
were male. Nearly a quarter of patients, 135 (20.9%), had
diabetes, 400 (62.0%) were hypertensive, 432 (66.9%) were
hyperlipidaemic, 122 (18.9%) were current smokers and 77
(11.9%) had a documented history of peripheral vascular
disease. Of the surgical group, 19 (4.5%) were also on extra-
corporeal membrane oxygenation and 7 (1.2%) were sup-
ported with right ventricular assist devices. More than half,
342 (53.0%), of the patients in whom counterpulsation was
utilised were in shock at the time of IABP insertion, with 279
(81.5%) of this group requiring inotropic and/or vasopressor
support.
IABP use in Dunedin and Christchurch
The characteristics of IABP use and the rate of major com-
plications group 1 (as listed in the Benchmark Registry) and
major complications group 2 are reported separately for
Christchurch and Dunedin Hospitals in Table 1. In Dunedin,
the majority, 149/153 (97.8%), of the cardiac surgery was
performed on bypass or ‘on pump’ and in Christchurch
the majority, 173/257 (67.3%), of coronary artery graft-
ing was ‘off pump’. Of the 645 IABPs placed, 242 (37.5%)
were placed in Dunedin and 403 (62.4%) were placed in
Christchurch (Table 1).
The indications for use were as follows: preoperative high-
risk cardiac surgery 233 (36.1%), AMI—the majority of whom
were shocked and undergoing primary PCI—131 (20.3%),
failure to wean from cardiopulmonary bypass 116 (17.9%),
intraoperative instability during ‘off pump’ cardiac surgery
42 (6.5%), postoperative cardiovascular instability 34 (5.3%),
AMI complicated by acute severe mitral regurgitation or ven-
tricular septal defect 26 (4.2%), post arrest with continuing
ventricular arrhythmias 26 (4.0%), emergent need for elective
PCI 15 (2.3%), AMI with refractory angina 9 (1.3%), left ven-
tricular failure 5 (0.8%), myocarditis 4 (0.6%) and prophylactic
use in high-risk elective PCI 4 (0.6%).

Table 1
Summary of IABP use of two New Zealand study centres compared to Benchmark Registry

Dunedin (n=242) Christchurch (n=403) Benchmark Registry as

published 2001 (n >16,900)
Mean number of IABP placed per annum 21 45 N/A
Prophylactic use for high-risk PCI 0% 0.6% (4) 20.6%
Predominant indication for use Assist wean from Preoperative support Prophylactic use for high-
cardiopulmonary bypass for predominantly ‘off risk PCI and during PCI
pump’ high-risk surgery
Prevalence of cardiogenic shock at time of insertion 72.2% (171) 41.8% (164) 18.8%
Average logistic EuroSCORE for surgical patients 13.9% (SD±13.6) 9.2 % (SD±12.8) N/A
In-hospital mortality 22.8% (36) 20.1% (81) 21.2%

Rate of major complication group 1 8.9% (14) 7.4% (30) 2.6%

Rate of major complication group 2 21.5% (34) 25.3% (102) N/A

*In-hospital mortality and major complication rates, group 1 and 2, not statistically different between Christchurch and Dunedin; P-values
0.48, 0.58, 0.35 respectively. Major complication group 1 is the same as the Benchmark Registry. This is a composite of death secondary to
counterpulsation, major limb ischaemia, balloon malfunction requiring premature removal, balloon rupture and haemorrhage secondary to
the IABP insertion requiring blood transfusion. Major complication group 2 is a composite of group 1 plus severe renal dysfunction, mesenteric
ischaemia and stroke. IABP=intra-aortic balloon pump, PCI=percutaneous intervention, EuroSCORE=European System for Cardiac Operative Risk
Evaluation, SD=standard deviation N/A=not applicable.

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Anaesth Intensive Care 2015 | 43:1 Does the final position of the IABP tip matter?

Table 2
Summary of univariant analysis as defined by final catheter position

Final position of the IABP tip as Acceptable (n=251) Unavailable (n=274) Malpositioned (n=72) Severely malpositioned Statistical
determined by chest radiograph (n=36) Significance
Cardiology setting 32.6% (63) 59.6% (115) 4.7% (9) 3.1% (6) P<0.001
Preoperative 55.9% (138) 27.9% (69) 11.7% (29) 4.5% (11) P<0.001
Intra/postoperative 25.2% (50) 46.6% (90) 17.6% (34) 9.8% (19) P<0.001
Fluoroscopy used 80.1% (201) 68.2% (187) 58.3% (42) 50.0% (18) P<0.001
Shock at time of insertion 41.2% (101) 63.6% (173) 49.3% (33) 61.1% (22) P<0.001
Major complication rate group 1 2.0% (5) 10.6% (30) 15.3% (11) 19.4% (7) P<0.001
Major complication rate group 2 15.5% (39) 25.2% (69) 47.2% (34) 75.0% (27) P<0.001
Incidence of severe renal dysfunction 10.0% (25) 12.8% (35) 31.9% (23) 66.7% (24) P<0.001
Severe catheter dysfunction 0.8% (2) 6.2% (17) 12.5% (9) 16.7% (6) P<0.001
In-hospital mortality 17.5% (44) 29.2% (80) 8.3% (6) 13.9% (5) P<0.001

Major complication group 1 is a composite of death secondary to counterpulsation, major limb ischaemia, balloon malfunction requiring premature
removal, balloon rupture and haemorrhage secondary to the IABP insertion requiring blood transfusion. Major complication group 2 is a composite of
group 1 plus severe renal dysfunction, mesenteric ischaemia and stroke. IABP=intra-aortic balloon pump.

IABP tip placement
Analysis of chest radiograph reports showed that the final
IABP position was acceptable in 251 (39.9%), malpositioned
in 72 (11.1%) patients and severely malpositioned in 43
(6.7%) patients. Chest X-ray data was unavailable for 274
(42.4%). Of these 274 cases, 99 (35.8%) had support for <2
or 2 to 12 hours. Twenty-five out of forty-one (60.9%) of the
<2 hour group and 24/58 (41.3%) of the 2 to 12 hour group
died. Of the patients in the unavailable group that had sup-
port for >48 hours, 108/119 (90.8%) had the devices placed
with fluoroscopic guidance.
To validate the use of chest radiograph reports in the analy-
sis, all digitally stored X-rays were assessed. Out of the 645
cases, 136 (21.1%) had digitally stored X-rays that could be
re-evaluated. All but one correlated with the report catego-
ries used (category changed from unavailable to acceptable).
Estimation of the degree of migration
In an attempt to estimate the degree of migration, patients
who received preoperative counterpulsation in Christchurch
between 2004 and 2008 were identified. Thirty-eight of the
101 patients had recorded cine images in the catheterisation
laboratory. In 35 cases of the 38, the IABP position before
and after surgery was successfully referenced according to
the distance between the radio-opaque tip to the aortic arch
by a consultant thoracic radiologist.
The preoperative cine imaging showed that 34/35 (97.1%)
were in an acceptable position with the average distance
being 24.7 mm from the arch. One out of 35 was in an
unacceptable position at 62 mm. The postoperative images
showed that 18/35 (51.4%) were still in an acceptable posi-
tion with 16 (45.7%) malpositioned (average distance from
arch being 69.7 mm) and 1 (2.9%) severely malpositioned at
140 mm, migrating down 78 mm. Therefore, in the 35 that
could be tracked accurately before and after surgery, the
average migration distance was 26.4 mm.
Major complications
The individual complication rates for the entire group were
as follows: severe renal impairment 107 (16.6%), severe cath-
eter dysfunction 35 (5.4%), severe bleeding 19 (2.9%), lower
limb ischaemia 17 (2.6%), stroke 15 (2.3%), balloon rupture
or leak 15 (2.3%), death related to counterpulsation 8 (1.2%),
mesenteric ischaemia 7 (1.1%), vessel perforation 3 (0.5%)
and entrapment 1 (0.2%).
Although the major complications group 1 rate in both
New Zealand centres are higher than the estimate from the
Benchmark Registry as published in 2001 (Table 1), subse-
quent frequencies from the Benchmark Registry are higher at
6.2%14,19. This may reflect a more real-life estimate as larger
numbers of centres join the registry.
Univariate analysis showed a striking stepwise increase in
major complication group 2 with an increasing degree of dis-
placement (Table 2). There was a higher incidence of major
complications if fluoroscopy was not or could not be used
for both major complications group 1 (without fluoroscopy:
28/193 patients (14.5%), with fluoroscopy: 27/452 patients
(6.0%), P <0.001) and major complications group 2 (with-
out fluoroscopy: 77/193 patients (39.9%), with fluoroscopy:
94/452 patients (20.6%), P <0.001).
Logistic regression analysis showed the final IABP position
was the strongest independent predictor of major complica-
tions group 2 (including renal dysfunction, mesenteric ischae-
mia and strokes). The risk of developing major complication
group 2 if the IABP was malpositioned was 3.9-fold (CI=2.0 to
7.6, P <0.001), and 13.0-fold (95% CI=5.3 to 31.7, P <0.001)
if the IABP was severely malpositioned. For those in whom

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 M. Siriwardena et al Anaesth Intensive Care 2015 | 43:1

Table 3
Logistic regression analysis of major complications group 2

Variable Beta Coefficient Standard Error Odds Ratio 95% Confidence P-value
Interval for Odds
Ratio
Lower Upper
Chest X-ray position
Malpositioned 1.369 0.334 3.932 2.023 7.642 <0.001
Severely malpositioned 2.564 0.456 12.98 5.317 31.715 <0.001
Unavailable 0.334 0.254 1.397 0.849 2.299 0.188
Age 0.019 0.010 1.018 1.00 1.04 0.064
Diabetes -0.195 0.269 0.823 0.485 1.395 0.469
Intra/postoperative setting 0.772 0.265 1.603 0.954 2.694 0.075
Shock 0.134 0.295 3.805 2.135 6.781 <0.001

Reference category for chest X-ray position was ‘acceptable’. Reference category for group setting was preop-
erative placement. Major complication group 2 is a composite of death secondary to counterpulsation, major
limb ischaemia, balloon malfunction requiring premature removal, balloon rupture, haemorrhage secondary
to the IABP insertion requiring blood transfusion, severe renal dysfunction, mesenteric ischaemia and stroke.
IABP=intra-aortic balloon pump.

Table 4
Logistic regression analysis of severe renal dysfunction (Creatinine rise >200 μmol/l)

Variable Beta Coefficient Standard Error Odds Ratio 95% Confidence P-value
Interval for Odds
Ratio
Lower Upper
Chest X-ray position
Malpositioned 1.303 0.372 3.681 1.776 7.633 <0.001
Severely malpositioned 2.872 0.450 17.669 7.319 42.652 <0.001
Unavailable 0.139 0.303 1.149 0.634 2.081 0.647
Age 0.013 0.011 1.013 0.991 1.035 0.259
Diabetes 0.179 0.296 1.196 0.670 2.136 0.545
Intra/postoperative setting -0.208 0.309 1.013 0.443 1.488 0.725
Shock 1.276 0.347 3.582 1.814 7.073 <0.001

Reference category for chest X-ray position was ‘acceptable’. Reference category for group setting was preop-
erative placement.

Table 5
Logistic regression analysis of major catheter dysfunction

Variable Beta Coefficient Standard Error Odds Ratio 95% Confidence P-value
Interval for Odds
Ratio
Lower Upper
Chest X-ray position
Malpositioned 2.769 0.807 15.946 3.276 77.618 0.001
Severely malpositioned 2.790 0.874 16.285 2.935 90.351 0.001
Unavailable 1.865 0.778 6.455 1.404 29.682 0.017
Age -0.003 0.018 0.997 0.963 1.032 0.844
Diabetes 0.135 0.471 1.145 0.454 2.884 0.772
Intra/postoperative setting 0.574 0.524 1.775 0.635 4.957 0.274
Shock -0.143 0.494 0.867 0.329 2.283 0.774

Reference category for chest x-ray position was ‘acceptable’. Reference category for group setting was preop-
erative placement.

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 Anaesth Intensive Care 2015 | 43:1 Does the final position of the IABP tip matter?

IABP Severely Malpositioned P<0.001 the final position was unavailable, the chance of develop-
IABP Malpositioned P<0.001 ing a major complication group 2 was 1.4 (CI=0.8 to 2.3,
IABP Position Tip Unknown P=0.188
P=0.188). In addition, shock was also independently prog-
Shock P<0.001
nostic of major complications group 2 (OR=3.8, CI=2.1 to 6.8
Diabetes P=0.469
P <0.001). Older age, a history of diabetes and the setting of
Surgical/Medical Setting P=0.075
which the IABP was placed (cardiology or surgical) were not
P=0.064
independently associated with major complications in group
Age
2 (Figure 2 and Table 3). Further logistic regression analysis
0.1 1 10 100
of the two most common major complications making the
Odds Ratio composite major complication group 2 were also examined,
Results of Logistic Regression Analysis of Factors Predictive of IABP Major Complications.
namely severe renal impairment—a creatinine rise of >200
Figure 2: LogisticData
regression
Presented asanalysis ofand
Odds Ratio factors predictive
95% Confidence of major complications
Interval. μmol/l (Figure 3 and Table 4) and severe catheter malfunc-
group 2. Data presented as odds ratio and 95% confidence interval. IABP=intra- tion (Figure 4 and Table 5) .
aortic balloon pump.

Discussion
Our review of counterpulsation therapy in two centres in
IABP Severely Malpositioned P<0.001 New Zealand showed that an unsatisfactory final IABP tip
IABP Malpositioned P<0.001 position was the main factor associated with subsequent
development of major complications. This is the first study to
IABP Position Tip Unknown P=0.647
investigate whether the final position of the IABP tip is asso-
Shock P<0.001 ciated with increased morbidity. When looking at all major
Diabetes P=0.545 complications, including severe renal dysfunction, stroke
and mesenteric ischaemia, the risk increased in a stepwise
Surgical/Medical Setting P=0.725
manner with increasingly poor tip placement from 3.9 to
Age P=0.259
13-fold. When looked at separately, the two most commonly
0.1 1 10 100 occurring major complications—severe renal dysfunction and
catheter dysfunction—also increased in a stepwise fashion.
Odds Ratio Previously, there have been case reports of misplaced cath-
eters causing impaired organ perfusion but the risk has not
Results of Logistic Regression Analysis of Factors Predictive of Severe Renal
Figure 3: Logistic regression
Dysfunction. analysis as
Data Presented of Odds
factors
Ratio predictive of severe
and 95% Confidence renal
Interval. been quantitated20,21.
dysfunction (creatinine rise > 200 μmol/l). Data presented as odds ratio and 95% With regards to increased incidence of severe renal dys-
confidence interval. IABP=intra-aortic balloon pump. function, IABP tip position remained the most significant risk
factor in this group. This may reflect impaired augmenta-
tion of cardiac output with malpositioned devices or direct
impairment of blood-flow distally, despite the deflation
IABP Severely Malpositioned P=0.001 during systole. Similarly, the increased incidence of mesen-
IABP Malpositioned P=0.001 teric ischaemia is intuitive and biologically plausible. Of the
IABP Position Tip Unknown P=0.017 patients suffering from strokes however, review of case files
Shock
commonly demonstrated an alternative cause such as pre-
P=0.772
existing severe carotid artery disease, mural thrombus or
Diabetes P=0.469
watershed type infarction secondary to periods of extreme
Surgical/Medical Setting P=0.274
hypotension. Interestingly, IABP tip position was not associ-
Age P=0.844 ated with increased mortality in this group.
0.1 1 10 100 The failure to adjust the misplaced devices possibly reflects
the perception that absolute detail to positioning is not
Odds Ratio required or that there may be increased risk of infection if
Results of Logistic Regression Analysis of Factors Predictive of Severe Catheter the IABP is advanced. Not uncommonly, physicians feel reas-
Figure 4: Logistic regression Presented
malfunction.Data analysis asofOdds
factors
Ratio predictive of major
and 95% Confidence catheter
Interval.
dysfunction. Data presented as odds rtio and 95% confidence interval. sured by other parameters such as the absence of acidosis
IABP=intra-aortic balloon pump. or adequate urine output. Some would argue that since the
IABP is deflated during systole, absolute attention to tip posi-
tion is not required. Our data would argue to the contrary.
This study also suggests that potential for tip migration may
be more common than appreciated.

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 M. Siriwardena et al
Limitations
Retrospective determination of factors associated with an
increased incidence of complications does not prove cause
and effect. With severe renal dysfunction for example, some
patients had multiple factors for developing this complication
including pre-renal factors such as hypoperfusion, exposure
to nephrotoxic agents such as contrast agents or undergoing
cardiopulmonary bypass. However, the increase in the risk of
major complications with worse catheter misplacement follows
a clear stepwise pattern, strongly suggesting cause and effect.
The final position of the IABP tip was not available in over
40% of patients. For those who received perioperative coun-
terpulsation, given the policy in both hospitals of obtaining
a chest radiograph as routine in intensive care admissions, it
may be that the team had assessed IABP tip position despite
this not being included in the radiographer’s report. It is also
possible that tip position was assessed by other means such
as transoesophageal echocardiography. Although the num-
ber with tip position being unavailable by radiograph reports
remains a potential limitation of this retrospective study, the
ORs are statistically robust. In addition, the IABP tip position
was entered as four separate groups into the logistic regres-
sion analysis. The risk estimates did not change appreciably
when the unavailable group was excluded from the analysis.
Finally, the consequences of malpositioned IABPs cannot be
ethically determined in a prospective study.
Conclusion
The acceptance of a less than ideal final position was highly
predictive of morbidity directly related to IABP device therapy.
The results would favour the initial placement of these devices
under direct imaging and highlight the importance of monitor-
ing final device position by chest radiograph or by other estab-
lished means such as transoesophageal echocardiography.
Particular care should be exercised in fixing the device in opti-
mal position from the outset of its deployment as the potential
for IABP tip migration may be underestimated.
Our findings suggest routine confirmation and documenta-
tion of final IABP tip placement should be mandatory with IABP
use, as this is likely to lead to improved complication rates.
Acknowledgements
The authors would like to acknowledge the input of Dr Leo
A. G. Celi, Intensivist, Boston, MA for advice on drafting this
manuscript, and the radiographers at the catheterisation
laboratory, Christchurch Public Hospital, for assistance in find-
ing the relevant cine images.
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