Preoperative use of intra-aortic balloon counterpulsation in very high-risk patients prior to urgent noncardiac surgery

The optimal management of high-risk patients requiring urgent or emergency noncardiac surgery when the options for further testing and evaluation are limited, is unclear. The focus of most of the literature, including the American College of Cardiology/American Heart Association guidelines, has been on patients undergoing elective as opposed to urgent surgery. A few reports have suggested the use of intra-aortic balloon counterpulsation as a strategy to help carry such patients through the procedure. We describe three such very high-risk patients who successfully underwent emergency surgery with prophylactic insertion of an intra-aortic balloon pump without any adverse cardiac events or device-related complications. Our experience, as well as that of others suggests that preoperative intra-aortic balloon counterpulsation is a useful (and safe) approach to help very high-risk patients undergo urgent and emergency noncardiac surgery. Randomized trials are needed to assess whether balloon counterpulsation offers an incremental benefit over aggressive preoperative beta blockade.