More than a century ago, Osler took numerous syndrome descriptions of cardiac valvular infection that were incomplete and confusing and categorized them into the cardiovascular infections known as infective endocarditis. Because he was both a clinician and a pathologist, he was able to provide a meaningful outline of this complex disease. Technical advances have allowed us to better subcategorize infective endocarditis on the basis of microbiological etiology. More recently, the syndromes of infective endocarditis and endarteritis have been expanded to include infections involving a variety of cardiovascular prostheses and devices that are used to replace or assist damaged or dysfunctional tissues (Table 1). Taken together, infections of these novel intracardiac, arterial, and venous devices are frequently seen in medical centers throughout the developed world. In response, the American Heart Association’s Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease wrote this review to assist and educate clinicians who care for an increasing number of patients with nonvalvular cardiovascular device–related infections. Because timely guidelines1,2 exist that address the prevention and management of intravascular catheter–related infections, these device-related infections are not discussed in the present Statement. 

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TABLE 1. Nonvalvular Cardiovascular Device–Related Infections 



This review is divided into two broad sections. The first section examines general principles for the evaluation and management of infection that apply to all nonvalvular cardiovascular devices. Despite the marked variability in composition, structure, function, and frequency of infection among the various types of nonvalvular cardiovascular devices reviewed in this article, there are several areas of commonality for infection of these devices. These include clinical manifestations, microbiology, pathogenesis, diagnosis, treatment, and prevention. The second section addresses each device and describes unique clinical features of infection. Each device is placed into one of 3 categories—intracardiac, arterial, or venous—for discussion.

### Clinical Manifestations

The specific signs and symptoms associated with an infection of a …

http://www.endocardites-aquitaine.fr/fileadmin/documents/documents/2003BADDOUR.pdf

Nonvalvular Cardiovascular Device–Related Infections

Between June 1967 and December 1982, 872 attempts at intraaortic balloon pumping (IABP) were made in 733 patients. Nearly 75% of the patients were men; the proportion of women has increased in recent years. The principal indication for IABP support initially was cardiogenic shock, but over the years, preoperative support, weaning from cardiopulmonary bypass and unstable angina have become the primary indications. Complications of IABP were classified and distributed by severity (minor: I [15%] and II [26%]; major: III [3%] and IV [1%]) and type ([vascular [22%], infectious [22%], and bleeding [7%]). Vascular complication rates were higher in women (32 vs 18%; p = 0.0001), in diabetic patients (32 vs 20%, p = 0.003), and in hypertensive patients (27 vs 20%, p = 0.02). These did not vary with the duration of IABP support (range of duration 0 to 76 days). The rate of infectious complications was related to location where IABP was performed (coronary care unit 26%, operating room 12%). The rate of fever and bacteremia increased significantly with duration of IABP support, but the rate of local wound infection did not. In conclusion, most IABP complications are minor, resolve after balloon removal, are related to vascular status of the patient and, with the exception of bacteremia, are independent of IABP duration.

Intraaortic balloon pumping 1967 through 1982: Analysis of complications in 733 patients

https://www.annalsthoracicsurgery.org/article/S0003-4975(02)03663-9/pdf

The intraaortic balloon pump in cardiac surgery.

Intraaortic balloon counterpulsation: Patterns of usage and outcome in cardiac surgery patients

Treatment with the intraaortic balloon pump (IABP) is the most common form of mechanical support for the failing heart. Augmentation of diastolic pressure during balloon inflation contributes to the coronary circulation and the presystolic deflation of the balloon reduces the resistance to systolic output. Consequently, the myocardial work is reduced. The overall effect of the IABP therapy is an increase in the myocardial oxygen supply/demand ratio and thus in endocardial viability. This is an overall synopsis of what we need to know regarding IABP. Furthermore, this review article attempts to systematically delineate the pathophysiology linked with the hemodynamic consequences of IABP therapy. The authors also look at the future of the use of the balloon pump and conclude that the positive multi-systemic hemodynamic regulation during IABP treatment should further justify its use.

/pdf/iabp-history-evolution-pathophysiology-indications-what-we-55xxdn1n1y.pdf

IABP: history-evolution-pathophysiology-indications: what we need to know

Data on 14, 168 adult patients undergoing surgery in the 44 months from November 1, 1975 to July 1, 1979 were analyzed to determine the incidence of need for escalating degrees of mechanical support of the failing circulation (intraaortic balloon pump, abdominal left ventricular assist device, or both) after cardiopulmonary bypass. Analyses were performed using a TRS-80 microcomputer to categorize the postoperative course of all adult patients undergoing open heart surgery. It was assumed that any patient who died despite pharmacologic and intraaortic balloon support was a candidate for more profound mechanical circulatory support, that is, the left ventricular assist device, which is 6 to 10 times more hemodynamically effective; on this basis, the latter device was needed in 430 cases (3 percent). A total of 12,669 patients (89.4 percent) were weaned from bypass without difficulty, 1,499 patients (10.6 percent) required pharmacologic agents and volume loading during weaning, 326 patients (2.3 percent) demonstrated inadequate responses to conventional pharmacologic therapy and required intraaortic balloon support during weaning, 94 patients (0.7 percent) demonstrated an inadequate response to conventional pharmacologic and balloon support and 21 patients (0.1 percent) underwent profound mechanical circulatory support (abdominal implantation of a left ventricular assist device).

Retrospective analyses of the need for mechanical circulatory support (intrasortic balloon pump/abdominal left ventricular assist device or partial artificial heart) after cardiopulmonary bypass. A 44 month study of 14,168 patients.

Four hundred nineteen patients with postoperative low output syndrome were supported with intraaortic balloon pumping between September 1, 1972 and June 1, 1979. Overall, 226 patients (54 percent) were successfully weaned from pumping support and 188 (45 percent) were subsequently discharged from the hospital. Approximately 10 percent of the patients died after apparently successful weaning from the balloon pump. Patients who underwent aortocoronary bypass operations had significantly better survival rates than patients who underwent combined aortocoronary bypass and valve procedures (60 versus 28 percent, p < 0.01). Two hundred sixty-three of the 419 patients have been serially classified hemodynamically since 1975. During intraaortic balloon pumping, 134 of these 263 patients ultimately achieved and maintained class A hemodynamic status (cardiac index greater than 2.1 liters/min, with systemic vascular resistance less than 2, 100 dynes s cm−5); all of these patients were successfully weaned from the balloon pump. Fortyone (16 percent) of the 263 patients achieved only class B status (cardiac index greater than 1.2 but less than 2.1 liters/min, systemic vascular resistance less than 2, 100 dynes s cm−5); the mortality rate in this group was 46.3 percent. Eighty-eight of the 263 patients failed to progress beyond class C status (cardiac index less than 1.2 liters/min or systemic vascular resistance greater than 2, 100 dynes s cm−5); the mortality rate was 96.6 percent during intraaortic balloon pumping. The differences in survival rates among patients in classes A, B and C were statistically significant (p < 0.001).

The mean ages of survivors and nonsurvivors were not significantly different. Men had a 59 percent and women a 47.3 percent survival rate (p < 0.05). The duration of support was 60.2 ± 44.7 hours in survivors and 10.9 ± 21.1 hours in nonsurvivors, suggesting an early high attrition rate for unsuccessful postoperative support. Patients with balloons of 40 and 30 ml had significantly better survival rates (67 and 52 percent, respectively) than patients with 20 ml balloons (47 percent, p < 0.05).

Treatment of postoperative low output syndrome with intraaortic balloon pumping: experience with 419 patients.

In an attempt to quantitate intra-aortic balloon pump (IABP) dependence and differentiate retrievable post-infarction cardiogenic shock situations, thirty-five patients were analyzed in regard to age, duration of IABP support, and hemodynamic performance. Survivors were younger than non-survivors (P 250 hours), there was a 100% mortality. IABP dependence was best recognized by time-course trajectory plots of cardiac index versus systemic vascular resistance. Three trends were observed. All patients who improved to Class A (CIgt; 2.1 L/min/m2, SVR 2100 dynes sec cm-5) expired early despite IABP support and were considered irretrievable.



This study suggests that post-infarction cardiogenic shock IABP-dependence can be quantitated to a certain degree. Post-infarction IABP-dependent patients are relatively young (40–55), do not expire during the first 50 hours of IABP support, neither improve nor deteriorate during the second 50 hours of support, and remain in Class B for 7–10 days without the occurrence of life-threatening ventricular dysrhythmias. In such situations, sufficient time may be available for cardiac catheterization to determine the appropriateness of subsequent operative interventions.

Michael G. McGee

Papers

Retrospective analyses of the need for mechanical circulatory support (intrasortic balloon pump/abdominal left ventricular assist device or partial artificial heart) after cardiopulmonary bypass. A 44 month study of 14,168 patients.

Treatment of postoperative low output syndrome with intraaortic balloon pumping: experience with 419 patients.

Quantitative Indices of Intra-Aortic Balloon Pump (IABP) Dependence During Post-Infarction Cardiogenic Shock