Which of the following are the major indications for instituting intra-aortic balloon pumping?

A. Medically refractory angina.

B. Acute papillary muscle rupture.

D. Ventricular failure after cardiac surgery.

E. PTCA failure

DISCUSSION: Medically refractory angina is one of the major indications for implementing the intra-aortic balloon pump. When intravenous nitroglycerin becomes ineffective at relieving chest pain or results in early hypotension, the balloon pump should be used in preparation for surgical revascularization or percutaneous angioplasty. By reducing left ventricular afterload, the pump reduces regurgitation into the left atrium. Thus, balloon counterpulsation is very helpful for treating patients with acute mitral insufficiency secondary to papillary muscle rupture. Patients should undergo valve surgical procedures emergently, as balloon pump support is only temporizing. The mere presence of a left main coronary lesion is not an indication for use of the balloon pump. In former years such pumps were inserted prophylactically before induction of anesthesia for coronary bypass surgery. Newer anesthetic techniques have largely obviated this; however, in the presence of a left main lesion and medically refractory angina the balloon pump should be used. The balloon pump is quite effective in helping to wean patients who have postcardiotomy left ventricular failure from cardiopulmonary bypass. This is one of the major uses of this device. The Emory University group was the first to expound on the efficacy of the balloon pump in stabilizing patients following percutaneous angioplasty failure. With the pump inserted, most patients can be transported to the operating room safely, many being stable enough to harvest an internal mammary graft instead of having to defer to the more accessible but less preferable saphenous vein.