J THoRAc CARDIOVASC SURG 80:760-763, 1980

Pulmonary artery balloon counterpulsation for

acute right ventricular failure
The development and availability of right ventricular assist devices has not kept pace with the evolution of
devices designed to mechanically support the systemic circulation. This report describes the application of
the counterpulsation concept to the pulmonary circuit to unload the failing right ventricle and augment
pulmonary blood flow. Conventional, widely available balloon pumping equipment was employed. Use of
this double balloon pump system enabled a patient to be weaned from cardiopulmonary bypass after all
other measures had failed. Other relevant potential clinical applications for this technique are discussed.

D. Craig Miller, M.D., Ricardo J. Moreno-Cabral, M.D., Edward B. Stinson, M.D.,

Julie A. Shinn, R.N., M.A., and Norman E. Shumway, M.D., Stanford, Calif.

T he development of right ventricular circulatory as-

sist devices has received little attention despite the rec-
ognition of its need in patients with certain varieties of
congenital heart disease undergoing corrective proce-
dures.! Furthermore, the clinical importance of right
ventricular infarctions- 3 and acute right ventricular
failure in patients supported with left ventricular assist
devices (L VADs)4, 5 has recently been appreciated.
We report a simple adaptation of the technique of
balloon counterpulsation for use in supporting the
acutely failing right ventricle. The balloon is placed in
a tubular graft, which functions as a reservoir, anas-
tomosed to the main pulmonary artery.

Case report
A 53-year-old man had an inferior myocardial infarction in
1970. This was followed by severe angina pectoris for which
he underwent double coronary artery bypass grafting to the left
anterior descending and obtuse marginal branch of the left
circumflex coronary artery in 1971. He was asymptomatic
thereafter until February, 1979, when he had a large
posterolateral myocardial infarction. A second massive an-
terolateral myocardial infarction occurred in May, 1979,
which was complicated by ventricular tachyarrhythmias and
left ventricular failure. Repeat coronary arteriography, per-
formed 2 months later because of severe angina, revealed a

From the Department of Cardiovascular Surgery, Stanford University

School of Medicine, Stanford, Calif.
Received for publication Feb. 28, 1980.
Accepted for publication April 22, 1980.
Address for reprints: D. Craig Miller, M.D., A206, Department of
Cardiovascular Surgery, Stanford University Medical Center,
Stanford, Calif. 94305.
Fig. 1. Schematic drawing of the two balloon counterpulsa-
tion systems. A 35 ml unidirectional intra-aortic balloon is
located in the conventional position in the descending aorta;
the pulmonary artery omnidirectional 35 ml balloon is in-
serted inside a tubular graft which is anastomosed to the main
pulmonary artery.

760 0022-5223/80/110760+04$00.40/0 © 1980 The C. V. Mosby Co.

Volume 80
Number 5 Pulmonary artery balloon counterpulsation 76 1
November. 1980

PAP
(To rr)
20 . 'tffiEmm1IJ:jfffE

Fig. 2. Pulmonary artery pressures (PAP) early postoperatively . A. Pulmonary artery balloon counterpulsation
system off: The pulmonary artery diastolic pressure is 24 torr and the peak pulmonary artery pressure is 35 torr.
B. Pulmonary artery balloon counterpulsation system activated at I : I ratio: The pulmonary artery end-diastolic
pressure (prior to opening of the pulmonary valve) is 22 torr, peak pulmonary artery systolic pressure is 31 torr,
and peak (counterpulsation) diastolic pressure is 36 torr .

dominant left coronary system with total occlusion of both 100 r - - -.......-....,..--,,..--.......- . . . . , . . - - , - ,
bypass grafts as well as the native right, left anterior descend-
ing, and the main circumflex coronary arteries . Diffuse distal ~
disease of the posterior descending, left anterior descending , w
a:
diagonal, and two obtuse marginal branches of the circumflex :l
~ 80
artery was also documented . Only a small, lateral-basal seg- w
ment of the left ventricle was contracting normally. Ejection ...a:
sa:
..J
fraction was estimated to be between 15% and 20%.
Despite maximal medical management , intractable angina w
>- 60
persisted , Accordingly, repeat myocardial revascularization a:
<l:
was undertaken in August, 1979. Four new coronary artery z
bypass grafts were constructed to the left anterior descending, <l:
w
diagonal , obtuse marginal , and posterior descending coronary ::;;
arteries . The duration of ischemia , for which profound topical 40 L-_....L..._~_---''-_-'-_.....L._--L---'

hypothermia and cold cardioplegia were used, was 62 min-

utes; cardiopulmonary bypass was discontinued with minimal
(2 mcg/kg /min) dopamine support .
One hour after return to the intensive care unit, the patient
exhibited repetitive ventricular tachycardia and ventricular
fibrillation that was refractory to pharmacologic suppression.
This necessitated open cardiac massage. He then was returned
to the operating room, where cardiopulmonary bypass was
reinstituted in an attempt to resuscitate the heart effectively.
Repeated attempts to wean the patient from cardiopulmo-
nary bypass were unsuccessful despite intra-aortic balloon
pumping and maximal inotropic support . All coronary artery
bypass grafts were patent. Although the pulmonary artery
pressure was not inordinately elevated, the right ventricle
became acutely distended with each weaning attempt; ven-
tricular tachycardia, which rapidly degenerated into ventricu-
lar fibrillation, occurred repeatedly, These arrhythmias and
obvious anterior right ventricular hypokinesis were consid-
ered to indicate a perioperative anterior myocardial infarc-
tion. Acute right ventricular failure was deemed to be the
principal limitation precluding weaning the patient from
bypass .
A second balloon counterpulsation system was inserted
into the pulmonary circuit by suturing a 20 mm low-prosity ,
woven Dacron tubular graft* to the main pulmonary artery.
Fig. 3. Mean systemic arterial pressure (MAP) plotted against
time. This graph shows generally higher MAP while the pul-
monary artery balloom pump (PABP) was activated. In addi-
tion, although not illustrated here, the arterial pressure would
become labile when the PABP was turned off for short inter-
vals. Atrial overdrive pacing was used to assist in suppressing
arrhythmias .
This graft functioned as a pumping reservoir for a 35 ml
omnidirectional balloon. * The linea alba was opened in-
feriorly to allow the graft housing the balloon to lie in the
preperitoneal plane (Fig. I) . With both balloons functioning
in concert, it was possible to discontinue cardiopulmonary
bypass after 3 hours of bypass support. Because of massive
cardiac dilatation, only the skin and subcutaneous tissues
were closed and the linea alba was loosely approximated
around the reservoir graft. One-to-one pulmonary artery bal-
loon counterpulsation provided an average peak pressure
augmentation of 5 torr during diastole and a presystolic un-
loading pressure of 4 to 5 torr (Fig . 2.) This therapy appeared

'Meadox Medicals, Oakland, N. J. 'Datascope Corp., Paramus, N. J .


762 Miller et al.
to be effective, as no further ventricular tachycardia or fibril-
lationoccurred for 24 hours. Lidocaine (4 mg/kg/min) and
moderate pharmacologic inotropic support (dopamine, epi-
nephrine, and nitroprusside) were also being administered.
No anticoagulants were used,
The patient's hemodynamic status improved steadily over
the first 30 postoperative hours, The pulmonary artery coun-
terpulsation rate was gradually reduced to a ratio of I ; 3 (Fig.
3). Not illustrated in Fig, 3 is the persistent trend of pulmo-
nary artery end-diastolic unloading that was generated by the
pulmonary artery balloon; furthermore, there was a gradual
decline in both the pulmonary artery systolic and peak dia-
stolic (counterpulsation) pressures. Maximum creatine phos-
phokinase level was 1,320 international units/liter (IU/L)
(13% MB fraction) and serum glutamic oxaloacetic trans-
aminase level was 136 Il.I/L, values which confirmed the
intraoperative suspicion of perioperative myocardial infarc-
tion. The patient was being prepared for return to the operat-
ing room for removal of the pulmonary artery balloon when
ventricular tachycardia and fibrillation recurred. This time the
arrhythmias were refractory to all resuscitative efforts.
Postmortem examination showed that the Dacron tubular
reservoir graft was entirely free of thrombus and all coronary
artery bypass grafts were patent. The heart was substantially
enlarged (540 gm) and the right ventricle was hypertrophic (6
to 7 mm). There was extensive chronic scarring in all regions
of the left ventricle. Additionally, fresh hemorrhage in the
superior interventricular septum suggested recent infarction,
Discussion
Conventional treatment for patients with ventricular
pump failure following intracardiac operative proce-
dures includes optimization of preload, inotropic sup-
port, and vasodilator therapy. 6 These measures are
combined with intra-aortic balloon counterpulsation if
necessary. Patients unresponsi ve to these modes of
therapy usually have died, although insertion of
paracorporeal left and right ventricular circulatory sup-
port devices:' or LVADs 7. 6 has resulted in rare sur-
vivors. Additionally, experimental work has been car-
ried out in which intracavitary balloons were used for
both right' and left ventricular support." These devices
are not widely available for clinical use; however, the
Litwak-Koffsky system is available and could have
been employed in this case by anastomosing the Litwak
cannulas to the right atrium and pulmonary artery. If
intractable, isolated, acute right ventricular failure were
to occur in a patient with a dominant right coronary
artery, another possible alternative would be to revas-
cularize the entire right coronary artery (using an ad-
junctive endarterectomy if necessary) to improve right
ventricular perfusion.
The basic advantages inherent in intra-aortic balloon
counterpulsation are twofold: reduction of impedance
to left ventricular emptying (afterload reduction) and
augmentation of diastolic coronary perfusion by in-
The Journal of
Thoracic and Cardiovascular
Surgery
creasing aortic mean diastolic pressure. Obviously,
only the former effect is possible with pulmonary artery
counterpulsation; however, the diastolic pressure aug-
mentation generated by pulmonary artery balloon
pumping may well augment transpulmonary blood flow
and, hence, assist left atrial and left ventricular filling.
This mechanism (which was not measured directly)
may explain the disparity between the relatively small
(2 to 5 torr) reduction in pulmonary artery end-diastolic
pressure and the favorable clinical observations,
In the case illustrated in this report, adaptation of the
basic principles of balloon counterpulsation for use in
the pulmonary circuit enabled cardiopulmonary bypass
to be discontinued in a patient who otherwise could not
be weaned from pump-oxygenator support. The system
can be assembled easily in any hospital with intra-aortic
balloon pumping equipment and expertise; miniatur-
ized components currently available!" may extend its
use to infants. Furthermore, intractable right ventricu-
lar failure has been a source of concern in the manage-
ment of patients requiring LVAD implantation- 11;
such circumstances might constitute another potential
application of this technique of pulmonary artery bal-
loon counterpulsation. Future application of this tech-
nique in patients with less advanced or more reversible
degrees of biventricular or right ventricular failure may
result in early and perhaps long-term survival.
REFERENCES
Sade RM: Correcting uncorrectable heart malformations.
Contemp Surg 12: 16-26, 1978
2 Isner JM, Roberts we: Right ventricular infarction com-
plicating left ventricular infarction secondary to coronary
artery disease. Am J Cardiol 42:885-894, 1978
3 Cohn IN: Right ventricular infarction revisited, Am J
Cardiol 43:666-668, 1979
4 Turina MT, Bosio R, Senning A: Paracorporeal artificial
heart in postoperative heart failure. Artif Organs 2:273-
276, 1978
5 Berger RL, Merin G, Carr J, Sussman HA, Bernhard WF:
Successful use of a left ventricular assist device in car-
diogenic shock from massive postoperative myocardial
infarction. J THoRAc CARDIOVASC SURG 78:626-632,
1979
6 Stinson EB, Holloway EL, Derby GC, Copeland JG,
Oyer PE, Buehler DL, Griepp RB: Control of myocardial
performance early after open-heart operations by vaso-
dilator treatment. J THORAC CARDIOVASC SURG 73: 523-
530, 1977
7 Pierce WS, Donachy JH, Landis DL, et al: Prolonged
mechanical support of the left ventricle. Circulation
58:Suppl 1:133-146, 1978
8 Koffsky RM, Litwak RS, Mitchell BL, Jurado R: A sim-
ple left heart assist device for use after intracardiac sur-
Volume 80
Number 5
November, 1980
gery. Development, deployment and clinical experience.
Artif Organs 2:257-262, 1978
9 Bregman D, Parodi EN, MaIm JR: Left ventricular uni-
directional intra-aortic balloon pumping. J THoRAc
CARDIOVASC SURG 68:677-686, 1974
IO Fukumasu H, Blaylock R, Veasy LG, et al: Intra-aortic
Pulmonary artery balloon counterpulsation 763
balloon pumping device for infants. Clin Cardiol 2:348-
353, 1979
II Golding LR, Groves LK, Peter M, Jacobs G, Sukalac R,
Nose Y, Loop FD: Initial clinical experience with a new
temporary left ventricular assist device. Ann Thorac Surg
29:66-69, 1980