Undiagnosed aortic dissection in patient with intra-aortic balloon pump.

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.

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. 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.

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

Figure 3

Transesophageal echocardiographic image showing dilated aortic root with dissecting aneurysm and dissecting flap

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]

Aortic dissection is seen in 1–4% of IABP insertions.[23] Catheter insertion into a false lumen 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.

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