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Intra Aortic Balloon Pump (IABP) Counterpulsation
P. J Overwalder, M.D. Department of Surgery I Division of Cardiac Surgery University Hospital Graz
Citation: P. J Overwalder: Intra Aortic Balloon Pump (IABP) Counterpulsation . The Internet Journal of Thoracic and Cardiovascular Surgery. 1999. Volume 2 Number 2.
Table of Contents
History Physiologic Effects of IABP Therapy Control of the IABP Insertion Techniques Complications Experience at a Single Center References
In 1958 Harken described for the first time a method to treat left ventricular failure by using counterpulsation or diastolic augmentation. He suggested removing a certain blood volume from the femoral artery during systole and replacing this volume rapidly during diastole. By increasing coronary perfusion pressure this concept would therefore augment cardiac output and unload the functioning heart simultaneously , . This method of treatment was limited because of problems with access (need for arteriotomies of both femoral arteries), turbulence and development of massive hemolysis by the pumping apparatus. Even experimental data showed that no augmentation of coronary blood flow was obtained .
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Then in the early 1960s Moulopoulus et al. , from the Cleveland Clinic developed an experimental prototype of the intra-aortic balloon (IAB) whose inflation and deflation
This advance made it for even nonsurgical personnel possible. Physiologic Effects of IABP Therapy After correct placement of the IAB in the descending aorta with it`s tip at the distal aortic arch (below the origin of the left subclavian artery) the balloon is connected to a drive console. continued by A. triggering selection switches and battery back-up power sources.5 to 9. Deflation occurs just prior to the onset of systole (Fig. The console itself consists of a pressurized gas reservoir. . 6 7 In its first years. In 1968 the initial use in clinical practice of the IABP and it`s further improvement was realized resp. The gases used for inflation are either helium or carbon dioxide .5 French was achieved .were timed to the cardiac cycle. 8 9 Today continued improvements in IABP technology permit safer use and earlier intervention to provide hemodynamic support. Inflation and deflation are synchronized to the patients’ cardiac cycle. Whereas carbon dioxide has an increased solubility in blood and thereby reduces the potential consequences of gas embolization following a balloon rupture. In 1985 the first prefolded IAB was developed. The advantage of helium is its lower density and therefore a better rapid diffusion coefficient. Figure 1: Intra aortic balloon (IAB) during systole and diastole . In 1979 after subsequent development in IABP technology a dramatic headway with the introduction of a percutaneous IAB with a size of 8. a monitor for ECG and pressure wave recording. Inflation at the onset of diastole results in proximal and distal displacement of blood volume in the aorta. All these progresses have made the IABP a mainstay in the management of ischemic and dysfunctional myocardium. . to perform an IAB insertion at the patient’s bedside. 1) . the IABP required surgical insertion and surgical removal with a balloons size of 15 French. adjustments for inflation/deflation timing. Kantrowiz`s group .
.1) 10 11 12 There are several determinants of oxygen supply and demand (Tab.The primary goals of IABP treatment are to increase myocardial oxygen supply and decrease myocardial oxygen demand. ejection fraction (EF). (Tab. Table 1: Hemodynamic effects of IABP Therapy Table 2: Determinants of Myocardial Oxygen Supply and Demand .2). improvement of cardiac output (CO). systemic perfusion and a decrease of heart rate. an increase of coronary perfusion pressure. Secondary. pulmonary capillary wedge pressure and systemic vascular resistance occur .
13 14 15 Figure 2: Schematic representation of coronary blood flow.In particular systolic wall tension uses approximately 30% of myocardial oxygen demand. . the integrated pressure difference between the aorta and left ventricle during diastole (DPTI = diastolic pressure time index) represents the myocardial oxygen supply (i. hemodynamic correlate of coronary blood flow) . the area under the left ventricular pressure curve.e. afterload. is an important determinant of myocardial oxygen consumption . enddiastolic volume and myocardial wall thickness. aortic and left ventricular pressure wave form with / without IABP. Wall tension itself is affected by intraventricular pressure. (Effects on DPTI and TTI . Balloon inflation during diastole augments diastolic pressure and increases coronary perfusion pressure as well as improving the relationship between myocardial oxygen supply and demand (DPTI:TTI ratio) . TTI (= tension-time index ). On the other hand. Regarding to the studies of Sarnoff et al.
the patient’s arterial waveform or an intrinsic pump rate. decreased myocardial oxygen consumption and increased cardiac output . Mainly balloon inflation is set automatically to start in the middle of the T wave and to deflate prior to the ending QRS complex. This is accomplished by either using the patient’s ECG signal. 16 Control of the IABP TRIGGERING To achieve optimal effect of counterpulsation. inflation and deflation need to be correctly timed to the patient’s cardiac cycle. In such cases the arterial waveform for triggering may be used. cardiac pacemaker function and poor ECG signals may cause difficulties in obtaining synchronization when the ECG mode is used. b) Deflation of the balloon occurs just prior to the onset of systole and reduces impedance to left ventricular ejection (TTI ). TIMING and WEANING . Tachyarrhythmias. This results in less myocardial work. The most common method of triggering the IAB is from the R wave of the patient’s ECG signal.• • a) Inflation of the balloon during diastole (= augmentation of the aortic diastolic pressure) increases coronary blood flow ( DPTI ).
noted on the dicrotic notch on the arterial waveform. Figure 3: Arterial pressure wave form alterations associated with inflation and deflation of the IAB If the patient’s cardiac performance improves. Balloon synchronization starts usually at a beat ratio of 1:2.It is important that the inflation of the IAB occurs at the beginning of diastole. Deflation of the balloon should occur immediately prior to the arterial upstroke. Errors in timing of the IABP may result in different waveform characteristics and a various number of physiologic effects (Fig. . 3). After appropriate observation at 1:8 counterpulsation the balloon pump is removed. This ratio facilitates comparison between the patient’s own ventricular beats and augmented beats to determine ideal IABP timing. weaning from the IABP may begin by gradually decreasing the balloon augmentation ratio (from 1:1 to 1:2 to 1:4 to 1:8) under control of hemodynamic stability .
. . Today more extending indications are: Cardiac patients requiring procedural support during coronary angiography and PTCA. failure to separate a patient from cardiopulmonary bypass and prophylactic applications. . Further on in pediatric cardiac patients and as well as in patients with stunned myocardium. 32 33 34 Table 3: IABP Counterpulsation Indications and Contraindications . There are successful reports of its usage in patients with aortic insufficiency . or as a bridge to heart transplantation. 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 IABP therapy should only be considered only for use in patients who have the potential for left ventricular recovery. Absolute contraindications of IABP are relatively few (Tab. or to support patients who are awaiting cardiac transplantation. . myocardial contusion. septic shock and drug induced cardiovascular failure the IABP can be life-saving . . . .Indications and Contraindications (Table 3) Early purposed indications for intraaortic balloon pumping have included cardiogenic shock or left ventricular failure. unstable angina. .3). . . . including stabilization of preoperative cardiac patients as well as stabilization of preoperative noncardiac surgical patients 10. and in patients with acute trauma to the descending aorta . . .
Insertion Techniques .
the balloon is threaded over the guide wire into the descending aorta just below the left subclavian artery. Finally the skin incision was closed. Continuing. a percutaneous placement of the IAB via the femoral artery using a modified Seldinger technique allows an easy and rapid insertion in the majority of situations. In patients with extremely severe peripheral vascular disease or in pediatric patients the ascending aorta or the aortic arch may be entered for balloon insertion . Removal of a percutaneously placed IAB may either be via surgical removal or closed technique. the femoral arteries were identified and controlled. . A vascular graft was then sewn to the common femoral artery in an end-to-side fashion. axillary or iliac arteries .5Fr dilator/sheath combination. The balloon was introduced into the artery via the graft and properly positioned in the thoracic aorta and the graft tightly secured to the distal portion of the balloon catheter. 35 36 37 38 39 . After a longitudinal incision in the groin. Since 1979. ideally so that the entire sheath is out of the arterial lumen to minimize risk of ischemic complications to the distal extremity. There are alternative routes for balloon insertion. Recently sheathless insertion kits are available. .therapy. Other routes of access include subclavian. Removal of the balloon required a second operation. The sheath is gently pulled back to connect with the leak-proof cuff on the balloon hub. .In the early years of IABP . After puncture of the femoral artery a J-shaped guide wire is inserted to the level of the aortic arch and then the needle is removed. Only the dilator needs to be removed. insertion of the balloon was performed by surgical cut down to the femoral vessels. The arterial puncture side is enlarged with the successive placement of an 8 to 10.
vascular injuries should be dealt with directly by surgical interventions and repair. . In general.Complications Although the incidence of complications has decreased significantly as experience with the device has increased. Till December 1993 a total number of 440 patients (pts) (9.(Age distribution : Tab. If signs of ischemia appear the balloon should be removed. It may occur in 14-45% of patients receiving IABP therapy . IABP therapy in today’s patients` population does still hold a risk for complications (Tab. Overall survival rate after implantation of the IABP was 75% (n=330 pts) . .80 years). were supported with an IABP. Therefore the patient must be consistently observed for any symptoms of ischemia during IABP counterpulsation. very often female and may suffer from severe peripheral vascular disease and hypertension or diabetes. 6) There were 294 male and 146 female patients. Because today’s patient population is elderly (68 .95%) out of 4420 patients. Balloon related problems and infection require removal and / or replacement of the IAB . The most common vascular complication is limb ischemia.4). who underwent cardiac surgery procedures with the use of cardiopulmonary bypass. 40 41 Table 4: Complications of IABP counterpulsation Experience at a Single Center Treatment of low cardiac output syndrome using IABP counterpulsation has been used at our institution since 1983.
Table 5: Diagnosis prior to IABP implantation .
Table 6: Age Distribution of IABP patients .
Kripke DC (1969) Hemodynamics and coronary blood flow with counterpulsation.mainly because of failure to wean from cardiopulmonary bypass -151 pts (34. Table 6 shows a detailed list of all various diagnoses prior to IABP therapy . Stephen R.5% (hospital mortality of 31. Harken DE (1958) Presentation at the International College of Cardiology.1%) developed a thrombosis of the femoral artery and 1 patient (0. Trans Am Soc Artif Int Org 7: 85 . Hospital mortality in this group was 36% (survival rate of 64%). Brussels.4%) died because of untreatable thrombosis of the mesenteric artery. 5 pts (2. After a learning curve more than 90% of 202 patients received an IABP using this technique. Complications were observed in 20 pts (8.In the early years (1983-1989) as method of choice. Moulopoulos SD. Surgery 65: 311 4. Harken DE (1976) Circulatory assist devices. References 1.5%) as a bridge to transplant. Survival rate was 68.7%) positioning of the balloon was impossible due to severe vascular disease.15). 3 infections of the puncture point and 4 cases of impossible positioning of the balloon ).3%) at an intensive care unit and 11 pts (2. Goetz RH. Belgium 2. 278 pts (63%) received the balloon pump at the operating theater . Med Instrum 10: 215 3. Topaz S et al (1962) Extracorporeal assistance to the circulation and intraaortic ballon pumping. Dormandy JA.5%) . Complication rate was less than 8% (mainly leg ischemia with amputation of the leg in 1 patient. implantation of the balloon was performed via a surgical cut down of the femoral artery. Mean pumping time was 3 days (1 . Since 1990 we prefer the percutaneous insertion of the device.4%) : In 9 pts (3.
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