Heart transplantation remains the best option for

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1 Ambulatory Intraaortic Balloon Pump Use as Bridge to Heart Transplant Richard P. Cochran, MD, Thomas D. Starkey, MD, Anthony L. Panos, MD, and Karyn S. Kunzelman, PhD Division of Cardiothoracic Surgery, University of Wisconsin, Madison, Wisconsin Background. This study evaluates a modification of an ambulatory intraaortic balloon pump (IABP) technique used in patients with heart failure of ischemic origin for bridge to transplant. Methods. In this retrospective review we evaluated the ability to place the ambulatory IABP, any complications, time on device, and success in bridging to transplant on the ambulatory IABP device. In addition, the cost as compared to current ventricular assist devices was determined. Results. Between July 2000 and November 2001, 4 patients have been managed with ambulatory IABP in our combined University of Wisconsin and William S. Middleton Veterans Administration programs. All 4 patients had ischemia as their mode of heart failure, and each had a relative contraindication to standard ventricular assist device use. All 4 patients had ambulatory IABPs successfully placed through the left axillary artery without complication, and were able to ambulate early after ambulatory IABP placement, and increased their rehabilitation status before transplantation. Ambulatory IABP support ranged from 12 to 70 days. All 4 patients have been successfully transplanted and discharged from the hospital. Use of the ambulatory IABP support, even with multiple replacements, translated to 10- to 50-fold savings for each of the reported patients versus standard ventricular assist device use. Conclusions. As a result of our initial experience, we believe that ambulatory IABP is an excellent mode of support in selected patients, and is cost-effective, as compared to conventional ventricular assist device therapy. (Ann Thorac Surg 2002;74:746 52) 2002 by The Society of Thoracic Surgeons Heart transplantation remains the best option for patients with end-stage heart failure who are refractory to medical therapy. Unfortunately, the availability of hearts for transplantation has plateaued in the past several years at 2,000 to 2,500 per year (2,314 in 1999, United Network for Organ Sharing Registry). With an ever-growing population with heart failure, this number remains woefully inadequate for the patients waiting each year. As such, alternative therapies such as mechanical devices have arisen as a means of sustaining organ function long enough to bridge the patient to transplant. There are many such ventricular assist devices (VADs) available now for left, right, or biventricular assistance. Unfortunately, there is no ideal device. In addition, these devices are costly and the operative procedure required for implantation has inherent risks of its own. Our center has an aggressive policy for bridge to transplantation and a complete compliment of VADs is used. Multiple devices are available; intraaortic balloons (IABP), Abiomed, Thoratec, and Heartmate (pneumatic and electrical), for all combinations of right, left, and biventricular support. The VAD use is tailored to the patient; however, some patients present with issues that Accepted for publication May 19, Address reprint requests to Dr Cochran, University of Wisconsin, CSC H4, 368, 600 Highland Ave, Madison, WI ; cochran@ surgery.wisc.edu. make the use of these devices less appealing. Thus, we have introduced a modification or combination of two previously described techniques that allow for ambulatory IABP use into this algorithm. This has been done in an effort to minimize risk to patients, to attain early mobility and rehabilitation, and to contain cost. Mayer [1] first described axillary/subclavian balloon insertion in a single patient in His technique required clavicular resection and was done on the right side. He did use a graft to aid in the insertion but did not advocate ambulation. McBride and colleagues [2] reported ambulatory IABP as a useful technique in the late 1980s. Their technique included isolation of the left axillary artery with direct cannulation of the artery through a pursestring suture. In addition, the catheter was tunneled subcutaneously along the chest wall and included external skin fixation for stability in ambulation. This technique also required return to the operating room for balloon removal. More recently, H Doubler and associates [3] reported a technique using a vein cuff sewn to the left axillary artery for facilitation of IABP placement in patients awaiting cardiac transplantation and Buchanan and colleagues [4] reported a technique for ambulatory IABP use, placed through the iliac artery. Both of these techniques have limitations. The use of a vein cuff would not easily allow multiple changes. The iliac placement also limits exchanges and is a more 2002 by The Society of Thoracic Surgeons /02/$22.00 Published by Elsevier Science Inc PII S (02)

2 Ann Thorac Surg COCHRAN ET AL 2002;74: AMBULATORY IABP AS BRIDGE TO TRANSPLANT 747 Patients and Methods Technique We have modified the referenced McBride technique [2], because waiting times for a transplant are much longer now than in the late 1980s, and balloon exchange may be necessary if the IABP catheter fails with long-term use. The left axillary artery is isolated, but instead of a pursestring suture and direct insertion a 4- to 8-mm expanded polytetrafluoroethylene vascular conduit graft is attached to the artery (Fig 1). This graft is then tunneled inferiorly for 8 to 10 cm and accessed through a separate small incision. The balloon is inserted with guidewire and fluoroscopic assistance through the expanded polytetrafluoroethylene graft, down the axillary and subclavian arteries into the descending aorta. Positioning is similar to conventional IABP, except the distal end is maintained above the renal arteries and the proximal balloon marker is positioned just below the subclavian artery in the descending aorta. Closure of the axillary exposure site is similar to closing a pacemaker pocket. Before closing the exit site for the Gore-Tex graft (W. L. Gore, Flagstaff, AZ), two large silk sutures (No. 2) are secured around the terminal portion of the conduit and the balloon shaft to prevent bleeding. The two silk sutures are placed approximately 1 cm from the skin incision, or as far up the skin tunnel as can be easily visualized, manipulated, and remaining accessible. The exit site is then secured. If there is excess motion of the external catheter beyond the tunnel, a second external site is chosen for anchoring to the lower chest or upper abdominal wall (depending on patient size) for minimizing motion during ambulation. For balloon exchange or removal, all that is required is local anesthetic for opening of the exit site, and a simple instrument tray for subcutaneous exploration. Fluoroscopic assistance is necessary for replacement or exchange, but is unnecessary for balloon removal. Fig 1. Intraaortic balloon pump, positioned in descending aorta, accessed through an expanded polytetrafluoroethylene vascular conduit graft to the left axillary artery. morbid operation. As such, an alternative approach that allowed ambulation and multiple easy exchanges seemed to be warranted. The purpose of this study is to report a modification of these techniques using a simplified ambulatory IABP technique that allows early ambulation and multiple balloon changes if necessary. The first 4 patients in whom this technique was used are reported. In addition, the cost effectiveness of this technology was evaluated. After this initial experience, we believe strongly that this technique should be considered more frequently in carefully selected patients. Indications for Ambulatory IABP Use The ideal patient is a patient with end-stage cardiomyopathy of ischemic origin who has failed or is failing on inotropic support, either due to on-going ischemia, arrhythmias, or worsening heart failure. Arrhythmias of ischemic origin can be successfully treated with balloon therapy; however, nonischemic arrhythmias would be refractory and were not considered for treatment by this method. In addition, for this initial experience, all patients had some relative contraindication for VAD support. Such conditions include massive ascites, very small body size, and reoperation. All patients should have a trial of standard IABP support to prove the benefit before conversion to ambulatory IABP. The left subclavian/ axillary arterial system should be free of disease. Patients who have a predictably long wait for transplant (ie, large patients with O blood type) may not be ideal as they will remain in hospital for the duration. However, if they have contraindications to VAD or if immediate rehabilitation is necessary, they too may be candidates for initial treatment with ambulatory IABP. Patient Population Between July 2000 and November 2001, 39 patients received heart transplants (35 orthotopic heart, 3 heart/ kidney, and 1 heart/lung) in our combined University of Wisconsin and William S. Middleton Veterans Administration programs. Seven of those patients received VAD therapy before transplant. (One additional patient who underwent VAD therapy was not transplanted.) During this time, there were only 4 patients who met the inclusion criteria as stated previously, and all 4 patients were managed with ambulatory IABP. All 4 patients had ischemia as their mode of heart failure. Review of patient data were approved by the University of Wisconsin Human Subjects Committee.

3 748 COCHRAN ET AL Ann Thorac Surg AMBULATORY IABP AS BRIDGE TO TRANSPLANT 2002;74: Patient 1 was a 53-year-old man cared for in the Veteran s Administration healthcare system, height 5 feet 10 inches (176 cm), weight 166 lbs (75.5 kg), and body surface area of 1.95 m 2. He presented with end-stage ischemic heart disease refractory to medical therapy and massive ascites with very poor conditioning. Ambulatory IABP treatment was chosen for this patient due to the desire of avoiding problems with his ascites and to allow for improved rehabilitation with minimal surgical setback. After proving the benefits of IABP in this patient with a femorally placed IABP, he was taken to the operating room for conversion to ambulatory IABP. Patient 2 was a 54-year-old man, height 6 feet 0 inches (180 cm), weight 220 lbs (100 kg), and body surface area of 2.2 m 2. He had previously undergone a successful heart transplant 14 years earlier and had developed ischemic disease in his graft. He underwent multiple interventional procedures in the cathetherization lab but was approaching end-stage disease. He was evaluated for retransplant and approved. However, his ischemia worsened requiring hospitalization and inotropic support that frequently worsened his ischemia. A trial femoral IABP was placed with a good response, in both hemodynamics and arrhythmias. He was converted to ambulatory IABP. Patient 3 was a diminutive, 44-year-old woman, height 5 feet 4 inches (160 cm), weight 115 lbs (52.3 kg), and body surface area of 1.5 m 2. She also had undergone coronary artery bypass grafting 3 years earlier. She had on-going refractory ischemic symptoms in the hospital. She remained refractory to pharmacologic therapy. A trial IABP was placed and she improved, and she was the converted to ambulatory IABP support. Patient 4 was also a diminutive, 52-year-old woman, height 5 feet 1 inch (152 cm), weight 132 lbs (60 kg), and body surface area 1.6 m 2 who had ischemic cardiomyopathy. She had no previous operation but had significantly elevated pulmonary artery pressures. Our concern was that biventricular support might be necessary, therefore a trial IABP was done with some improvement. She was converted to ambulatory IABP 4 days later. With regard to potential for arteriosclerosis, all patients had a trial femoral artery balloon first. If there were to be complications due to arteriosclerosis in the descending aorta, this would have likely been seen at that time, and the patient would not have proceeded to ambulatory IABP. Before ambulatory IABP placement, all patients were evaluated with physical examination and were documented to have equal blood pressures in both upper extremities. The left side is chosen versus the right, as one of the primary failure modes for all IABP patients is angulation or kinking in the driveline. Utilization of the left axillary artery allows more reliable direct access to the aorta, with less potential for bending or kinking of the driveline, as compared to using the right axillary artery. All ambulatory IABP patients are anticoagulated within 48 hours of balloon placement per our institutional protocol, and all patients were treated with perioperative antibiotics. Due to pulmonary artery hypertension or need for right ventricular support, inotropic and afterload reducing therapy was continued in all patients. Cost Analysis The cost was evaluated for the trial IABP placement, the initial ambulatory IABP placement, and any subsequent balloon catheter replacements for each of the 4 patients. This was compared to the cost of four types of VADs (Heartmate, Heartmate VE, Abiomed, and Thoratec), including device cost and the daily console rental fee, if applicable. This calculation was done assuming the patient would have been on the VAD for the same number of days as the ambulatory IABP, while awaiting transplant. For simplicity, device costs only were considered, and the cost of the operating room was excluded. This is due to the variable nature for VAD implant, that is, some implant procedures are straightforward and relatively fast (4 to 5 hours operating room time), whereas others may take several more hours and require massive transfusions and have a relatively high rate of return to the operating room for bleeding/evacuation of clot. Conversely, the ambulatory IABP procedures take only 60 to 90 minutes, and thus the operating room cost is much reduced. Thus, the exclusion of operating room costs gives a conservative analysis of savings due to ambulatory IABP placement. Routinely, the VAD of choice is the Heartmate VE, which allows for discharge. None of these candidates were considered good candidates for the VE. As such, the potential reduction in cost of hospitalization due to discharge was not an option for any of these patients. Realizing this, the hospital daily charge is the same with either therapy, and is not calculated. Results Patient 1 was supported on the ambulatory IABP for 46 days. He had no problems with the original balloon and no changes were necessary. He had no complications and was transplanted successfully on postoperative day 46 with ambulatory IABP removal in the operating room. Patient 2 was supported for 70 days, and required four balloon exchanges for leak in external housing, rupture, malfunction, and catheter fracture. Otherwise, he had no complications and was transplanted on postoperative day 70 with ambulatory IABP removal in the operating room. Because this patient had a prior transplant, his panel reactive antibody was checked, and on multiple preoperative checks the patient s panel reactive antibody was zero, and thus was not a contributor to any problems. It is uncertain why there were more problems with this balloon therapy, other than the fact that this was the largest patient, and had the smallest conduit (4 mm) used. Patient 3 had balloon support for 12 days, had no complications, and had no balloon exchanges. She was transplanted on postoperative day 12 with ambulatory IABP removal in the operating room. Patient 4 was supported for a total of 15 days. In this

4 Ann Thorac Surg COCHRAN ET AL 2002;74: AMBULATORY IABP AS BRIDGE TO TRANSPLANT 749 Table 1. Symptoms and Hemodynamic Profile Variables Patient #1 Patient #2 Patient #3 Patient #4 Pre Post Pre Post Pre Post Pre Post Symptoms Dyspnea, ascites Resolved Angina, arrhythmia Angina resolved, arrhythmia decreased Angina Angina resolved Angina, arrhythmia Angina resolved Cardiac output Cardiac index CVP PA pressure 71/48 41/22 31/25 24/20 48/26 73/42 79/42 44/23 PCWP PVR patient, pulmonary artery pressures initially improved but then started to increase and her cardiac indices remained marginal. She had one episode of catheter fracture requiring ambulatory IABP exchange. This was likely due to her short stature, resulting in a relatively greater effective curvature in her ambulatory IABP catheter. She was fortunate to get an appropriate donor (ie, slightly larger), with some right ventricular conditioning, within days of a scheduled conversion to VAD support. She underwent orthotopic cardiac transplant on postoperative day 15. Her ambulatory IABP was left in for 4 days after transplantation because right-to-left filling was tenuous early on, even with nitric oxide and vasodilator therapy directly in the pulmonary artery through a Swan- Ganz catheter. Once right-sided conditioning improved by echocardiography, the ambulatory IABP was removed at the bedside without complications. All patients were able to ambulate and increase their rehabilitation status before transplantation with the placement of the ambulatory IABP. Improvement in symptoms and hemodynamic profile was seen in all patients (Table 1). All 4 patients have been successfully transplanted, and have been discharged from the hospital. Cost The cost of an IABP catheter in our institution is $960 (Table 2). Patients 1 and 3 had one trial IABP and one ambulatory IABP for a total device cost of $1,920. Patient 2 had a total of six balloons (one trial IABP and five ambulatory IABPs) placed before transplant, for a device cost of $5,760. Patient 4 had one trial IABP and two ambulatory IABPs for a total device cost of $2,880. For comparison, the costs for standard VADs are Table 2. Comparison of Ambulatory Intraaortic Balloon Pump Cost to Standard Ventricular Assist Device Costs Variables Patient 1 Patient 2 Patient 3 Patient 4 Number of days on device Number of AIABP replacements Trial IABP cost $960 $960 $960 $960 AIABP initial cost $960 $960 $960 $960 AIABP replacement cost $0 $3,840 $0 $960 Total AIABP cost $1,920 $5,760 $1,920 $2,880 Heartmate cost $70,150 $70,150 $70,150 $70,150 Heartmate console rental ($284/day) $13,064 $19,880 $3,408 $5,396 Total Heartmate cost $83,214 $90,030 $73,558 $75,546 Heartmate VE cost $95,100 $95,100 $95,100 $95,100 Heartmate VE rental (none) $0 $0 $0 $0 Total Heartmate VE cost $95,100 $95,100 $95,100 $95,100 Abiomed cost $13,100 $13,100 $13,100 $13,100 Abiomed console rental ($900/day) $41,400 $63,000 $10,800 $17,100 Total Abiomed cost $54,500 $76,100 $23,900 $30,200 Thoratec cost $80,500 $80,500 $80,500 $80,500 Thoratec console rental ($284/day) $13,064 $19,880 $3,408 $5,396 Total Thoratec cost $93,564 $100,380 $83,908 $85,396 AIABP ambulatory intraaortic balloon pump; IABP intraaortic balloon pump.

5 750 COCHRAN ET AL Ann Thorac Surg AMBULATORY IABP AS BRIDGE TO TRANSPLANT 2002;74: provided. If the pneumatic Heartmate had been used in any of these patients, the cost for the device would have been $70,150 plus rental for the console at $284 per day. The lowest cost device is the Abiomed LVAD at $13,100 and the console rental is $900 per day. However, this is routinely used as a short-term device, and there would be a probable need for device change if an Abiomed LVAD were used for longer periods such as for patient 1 (46 days) or patient 2 (70 days). A longer use device with potential for discharge from the hospital, is the Heartmate VE. The device cost is $95,100, but it does not require console rental as it is electrically/battery supported. The cost for the Thoratec device would have been $80,500 plus rental for the console at $284 per day. Whichever VAD option is chosen for comparison, use of the ambulatory IABP, even with multiple replacements translates to 10- to 50-fold savings for each of the reported patients. If a Heartmate VE was used, where a patient could potentially be discharged from the hospital, there could be a reduction in charges for hospital room charges, which will vary by hospital. However, in the case of our 4 patients, the Heartmate VE was contraindicated in each of these patients. Even if one plays the devil s advocate and adds in multiple returns to the operating room for balloon exchange in some patients, the cost savings is still evident. This is because the exchange is a percutaneous procedure and takes less than 30 minutes. Thus, the total operating room cost for all five ambulatory IABP replacements would be less than the operating room time for one initial VAD procedure, and thus not including these costs is reasonable. Comment Heart failure is the most rapidly growing diagnostic related group in cardiovascular disease. End-stage heart failure at present only has one long-term solution, that is, transplantation. Because there are too few organs for the annual demand for transplantation, alternative therapies must be pursued. Unfortunately, the current VADs are extremely expensive. In addition, operative implant of a VAD has significant risks, particularly for postoperative bleeding and its attendant complications. Thus, it is essential that surgeons consider all modalities that can be beneficial but also that can contain cost. This initial small series of patients demonstrates that ambulatory IABP provided an excellent bridge to transplant in 3 of the 4 patients and showed a modest improvement in the fourth. There were no device-related infections or any bleeding or embolic complications in the hospital or long term, even with multiple balloon exchanges. All patients took perioperative antibiotics. None of the grafts required removal due to infection, false aneurysm, and other factors. There were no longterm complications in the axillary artery or left upper extremity noted in any patient. On the basis of the initial data, the ideal graft size is 6 mm, which matches best with the balloon for ease of insertion and removal without redundancy or excessive dead space. Because foreign materials in immunosuppressed patients could be problematic, one must be prepared to remove the grafts if necessary. However, the use of the ribbed Gore-Tex grafts is necessary to allow for multiple balloon exchanges. Multiple exchanges with a pursestring would not be possible, and would be problematic with a vein graft due to possible damage and the necessity of shortening the vein graft at the point of securing the hemostatic ties around the balloon catheter at each exchange. As discussed previously, there were no infectious complications, thus the potential for problems were not realized. There are several obvious advantages to ambulatory IABP over VAD use, including cost containment. From a surgical point of view, ambulatory IABP is technically much simpler. Ambulatory IABP avoids a sternotomy and the need for cardiopulmonary bypass. Furthermore, at the time of transplant, the removal of ambulatory IABP is quite simple and as in the case of our fourth patient, the ambulatory IABP can be used after transplantation. Conversely, a VAD implantation requires an obligatory sternotomy and additional cardiopulmonary bypass. In addition, the removal of a VAD is often difficult and has attendant complications. In addition, if assistance is needed after transplantation, VAD insertion is far more complex than continuation of ambulatory IABP. Finally, an additional advantage of IABP versus VAD therapy is that there is no report of increasing panel reactive antibody with IABP, whereas it is a common problem with VADs. There are also advantages of ambulatory IABP over VAD as far as the support team is concerned. The nursing expertise for IABP management already exists in all cardiac units. As such, expanding its use to the telemetry unit is done easily and uneventfully. There is always plenty of expertise to assist in troubleshooting any IABP problems, whereas the VAD units are managed by a select group of individuals with special knowledge. This makes availability and expedient management more difficult for VAD than ambulatory IABP. The VAD portable consoles are rapidly improving, but they are nowhere close to the ease of portability now found in the Datascope System 98XT portable console for ambulatory IABP use. Patients can easily push their own ambulatory IABP console around the telemetry unit with minimal initial conditioning, and often within days of operation. Our typical VAD patient is not ambulatory on telemetry for at least a week after operation. The minimal surgical impact of the ambulatory IABP versus VAD is obvious, based on its simplicity. The insertion of any of the VADs is a major operation with attendant cardiopulmonary bypass in the majority of patients and a huge metabolic and nutritional insult to these critically ill patients. Frequently, after VAD implantation, patients have to be taken off the transplant waiting list until they are stabilized or adequately recovered to undergo transplant. The ambulatory IABP patients can be extubated early, ambulated within hours to days of operation, and could be transplanted the same day of insertion if circumstances dictated without fear of added risks. With

6 Ann Thorac Surg COCHRAN ET AL 2002;74: AMBULATORY IABP AS BRIDGE TO TRANSPLANT 751 regard to the potential negative aspects of the technique, there is a small risk of thromboembolism and a small risk of vascular compromise in an atherosclerotic subclavian artery. The contraindications are in patients who do not have ischemic disease or those who have not responded favorably to IABP in the trial period. At present an additional negative aspect of ambulatory IABP therapy is that these patients cannot be discharged, as can the patients with Heartmate VE. However, in our institution this is not as large an issue, as historically there is a relatively short wait for status IA and IB patients, as compared to other institutions. In conclusion, after our initial experience, we believe that ambulatory IABP is an excellent mode of support in selected patients. The ideal patient has an end-stage cardiomyopathy of ischemic origin, refractory to inotropic support, and with a relative contraindication to VAD support. This modified technique of placement of a small expanded polytetrafluoroethylene vascular graft attached to the axillary artery and then tunneled subcutaneously to a remote access site on the skin facilitates rapid catheter exchange in the event of failure. This technical modification is easy to accomplish for any surgical team and makes replacement and removal quite easy. The advantage versus the H Doubler axillary vein graft technique is that the Gore-Tex graft allows for multiple exchanges of the balloon without having to shorten the graft, as would be necessary with a vein graft. In addition, in comparison to the Buchanan iliac artery technique for ambulatory IABP, the axillary approach is much simpler and allows for multiple exchanges of the balloon. There are multiple clear advantages to the use of ambulatory IABP. The ambulatory IABP is a simpler, faster, and safer operation than VAD insertion. The ambulatory IABP uses familiar technology for nursing personnel. The exchange in the rare device failure is easy and has minimal impact to the patient. With the ambulatory IABP, early ambulation and rehabilitation is easily accomplished. There is a clear and huge cost containment benefit for ambulatory IABP versus VAD. For these reasons, we are continuing to develop this technique and are using it more aggressively in a wider patient population. References 1. Mayer JH. Subclavian artery approach for insertion of intraaortic balloon. J Thorac Cardiovasc Surg 1978;76: McBride LR, Miller LW, Naunheim KS, Pennington DG. Axillary artery insertion of an intra-aortic balloon pump. Ann Thorac Surg 1989;48: H Doubler PB, H Doubler WZ, Bien RC, Jansen DA. A novel technique for intra-aortic balloon pump placement via the left axillary artery in patients awaiting cardiac transplantation. Cardiovasc Surg 2000;8: Buchanan SA, Langenburg SE, Mauney MC, et al. Ambulatory intraaortic balloon counterpulsation. Ann Thorac Surg 1994:58: INVITED COMMENTARY The authors from the University of Wisconsin present their small experience with the use of balloon counterpulsation in an ambulatory fashion (AIABP) as a bridge to transplantation. The recipients of this modality of support suffered from ischemic pathologies and had relative contraindications to the institution of more sophisticated mechanical support. As with all medical technologies and surgical endeavors, success is largely contingent upon patient selection; hence, the limitations of balloon support must be underscored. Balloon counterpulsation improves cardiac output in the order of 10% to 15%, does not displace volume, and cannot be considered a true assist device. Desperately ill patients requiring left ventricular replacement, would not benefit sufficiently from this mode of support. For patients with significant arrhythmias or those with normal coronaries, balloon counterpulsation may not be effective. Finally, institution of IABP support in patients with significant atherosclerotic disease of the left subclavian system and/or descending aorta could prove disastrous. The idea and technique of ambulatory balloon support, though not new, has been successfully modified and expanded by the authors to serve as a bridge to transplantation. Several advantages of this approach should be highlighted. First, and perhaps most attractive, is that a trial of effectiveness with conventional balloon support can be undertaken. Second, the modified technique reduces the chance of driveline kinking, permits normal ambulation, and allows easy access for balloon exchange(s) if necessary. One should not disregard the physical and psychological benefits derived from avoidance of the bedridden state in the hospital setting. Third, presence of an IABP at the time of transplantation does not complicate native heart excision and, in fact, can aid in separation from cardiopulmonary bypass in the event of right ventricular dysfunction. Last, compared to current mechanical support systems, the AIABP represents a relatively inexpensive alternative. The contraindications that led the authors to pursue AIABP support included ascites (presumably right heart failure related), advanced transplant vasculopathy, and small body size. At present, these contraindications can be addressed by more sophisticated (albeit more expensive, invasive, and less ubiquitous) systems like the biventricular Thoratec system and the second generation axial flow pumps (e.g., Micromed-DeBakey VAD, Jarvik 2000). It is of interest that the AIABP concept has been carried one step further by the CardioVAD system, an 2002 by The Society of Thoracic Surgeons /02/$22.00 Published by Elsevier Science Inc PII S (02)