IABP or IABC

Dr. Mofassel Uddin Ahmed Assistant registrar, cardiac surgery

Moderator: Dr. Mohammad Golam Kibria Associate professor, cardiac surgery

History
In 1950 and 1960 several physicians began looking at ways to assist the failing heart. In 1958 Dr. Harken and co-worker developed a model based on the idea by withdrawing a quantity of blood from the arterial system during systole and returning it during diastole. In 1960 SD Moulopolous introduce the concept of intra aortic balloon counterpulsation. IABP was first successfully used by Kantrowitz et al. in 1967
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What is IABP
It consists of a cylindrical balloon that sits in the aorta and counter-pulsates (Inflates during diastole and deflate during
systole).

It is in fact a system of volume displacement device which is used to decrease myocardial oxygen demand while at the same time increase the cardiac output as well as coronary blood flow.

Different parts
Double lumen catheter with a distal sausage shaped nonthrombogenic polyurethane balloon. Pump, equipped with a console display to view the ECG, aortic and balloon pressure waveforms. Central lumen extends to the catheter tip. Serves as a transducer to measure aortic pressure.

Central lumen is concentric with and situated inside the helium channel which is used for balloon inflation.
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ECG

Arterial waveform

Balloon pressure waveform

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IABP Kit Contents

Introducer needle Guide wire Vessel dilators Sheath IABP (34 to 40cc) Gas tubing 60-mL syringe Three-way stopcock Arterial pressure tubing

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The IAB Catheter

Catheter Inner Pressure Lumen Gas Shuttle Lumen Catheter Tip Membrane Sheath

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IAB Inflation

The balloon is timed to inflate at the onset of diastole and will remain inflated throughout diastole. The balloon is timed to begin inflation when the aortic valve closes. The dicrotic notch is used as a landmark for this event in the cardiac cycle.

The goal of inflation is to increase or augment perfusion.

Augmentation of diastolic pressure Increase coronary perfusion

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Inflation of IABP Results In:

Increased coronary perfusion pressure Increased systemic perfusion pressure Increased O2 supply to both the coronary and peripheral tissue Increased baroreceptor response Decreased sympathetic stimulation causing decreased HR, decreased SVR, and increased LV function

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IAB Deflation
Occurs in systole Just before ventricular ejection Just prior to the pre-ejection period (PEP), or isovolumetric contraction.

The goal of deflation is to reduce LV workload, creating a "potential space" in the aorta, reducing aortic volume and pressure

Decrease cardiac work

Decrease myocardial oxygen consumption Increase cardiac output
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Deflation of the IABP Results In:

Afterload reduction and therefore a reduction in MVO2 Reduction in peak systolic pressure, therefore a reduction in LV work Increased cardiac output Improved ejection fraction and forward flow

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Primary Effects of IABC

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Secondary Effects of IABC

Cardiac Output
Heart Rate PAD PCWP SVR B/P Systolic Diastolic MAP Diastolic Augmentation

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Insertion Of IABP

IAB Catheter Insertion

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Preparing the IAB Catheter

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For Sheathless Insertion

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For Sheathed Insertion

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Connection to IABP

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Animation of Insertion

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The IAB Catheter placement

Tip of the IAB catheter
Approx. 1-2cm distal to left subclavian artery.

Base of balloon membrane

Positioned above the renal arteries avoid compromise to renal perfusion avoid abrasive trauma to balloon membrane from plaque

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 The IAB catheter should be positioned between the second and third intercostal space.

Position should be confirmed by fluoroscopy or chest x-ray

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 If fluoroscopy is not available, measure the tip of the IAB from the sternal Angle of Louis to the umbilicus and then obliquely to the femoral insertion site.
(Note: An x-ray must be taken as soon as possible after insertion to correctly identify placement.)

Too High

Ideal

Too Low

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Size of the balloon

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Balloon catheter volume is selected according to patient height. The most frequently used balloon catheter is the 40 cc. 36

The Mechanics of Balloon Counterpulsation

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Principles of the IABP

A flexibile catheter is inserted into the femoral artery and passed into the descending aorta. When inflated, the balloon blocks 7080% of the aorta.
(Complete occlusion would damage the walls of the aorta, red blood cells, and platelets).
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Animation of mechanism

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The physiologic effects of IABP therapy

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Determinants of Myocardial Oxygen Supply and Demand

Coronary Artery Anatomy Diastolic Pressure Diastolic Time Oxygen Extraction Hemoglobin PaO2

Heart Rate Afterload Preload Contractility

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In different pathology

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What really the IABP does

Decreases systolic aortic pressure and increases diastolic
aortic pressure
Decreases afterload and preload Increases coronary blood flow, cardiac output, and renal blood flow

Decreases systolic and end-diastolic LV pressure

Decreases LV volume, stroke work, and wall tension
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Effects of IABC

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Indications

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1. Refractory unstable angina 2. Impending infarction

3. Acute MI
4. Refractory ventricular failure 5. Complications of acute MI 6. Cardiogenic shock 7. Support for diagnostic, percutaneous revascularization, and interventional procedures
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Indications..
8. Ischemia related intractable ventricular arrhythmias 9. Septic shock

10. Intra-operative pulsatile flow generation 11. Weaning from bypass 12. Cardiac support for non-cardiac surgery

13. Prophylactic support in preparation for cardiac surgery

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Indications..
14. Post surgical myocardial dysfunction/low cardiac output syndrome 15. Myocardial contusion

16. Mechanical bridge to other assist devices

17. Cardiac support following correction of anatomical defects

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Top seven indication of IABP according to

Benchmark registry (1st large registry of IABP)
1.
2. 3. 4. 5. 6. 7.

Hemodynamic support during or after catheterization

(20.6%)

Cardiogenic shock (18.8%) Weaning from cardiopulmonary bypass (16.1%) Preoperative use in high risk patients (13%) Refractory unstable angina (12.3%) Refractory ventricular failure (6.5%) Mechanical complication due to acute MI (5.5%)

source: Ferguson JJ et al. J Am Coll Cardiol. 2001; 38:1456-62 49

Contraindications
Absolute Severe Aortic Valve insufficiency Dissecting aortic aneurysms (Abdominal or Thoracic) Relative Severe calcific aorta-iliac disease or peripheral vascular disease (atherosclerosis) Abdominal aortic aneurysm Sheathless insertion with severe obesity, scarring of the groin Blood dyscrasias Thrombocytopenia
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Triggering

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 Trigger is the physiologic signal used by the balloon pump to identify the beginning of a new cardiac cycle and to deflate the IAB if it is not already deflated. In most cases it is preferable to use the R wave of the ECG as the trigger signal

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Triggering on the Arterial Pressure Waveform

There are other trigger options for instances when the R wave cannot be used or is not appropriate Arterial pressure provides another signal to the IABP It is used when the ECG has too much interference from patient movement or poor lead connection

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Trigger Event

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Timing Assessment
120 C Increased Coronary Artery Perfusion F D Balloon Inflation

mm 100 Hg B 80

B E

Reduced Myocardial O2 Demand

D = Augmented Diastole E = Assisted End Diastole F = Assisted Systole

A = One cardiac cycle B = Unassisted End Diastole C = Unassisted Systole

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Review of Arterial Pressure Landmarks

AVO = Aortic valve opens, beginning of systole PSP = Peak systolic pressure, 65-75% of stroke volume has been delivered DN = Dicrotic notch, signifies aortic valve closure and the beginning of diastole

AEDP = Aortic end diastolic pressure

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Normal Balloon Pressure Waveform

Peak Inflation (Positive Overshoot)

Plateau (Full inflation of IAB)

IAB Inflation

IAB Deflation

Zero Baseline

Return to Zero Baseline

Peak Deflation (Negative Overshoot)
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Normal Waveform Variations

Tachycardia Bradycardia

Hypertension

Hypotension

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Variations in Balloon Pressure Waveforms

Gas Loss

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Variations in Balloon Pressure Waveform

Catheter Kink

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IABP Timing Modes

Automatic Tracks cardiac cycle, cardiac rhythm and adjusts automatically Semi-Automatic Operator must adjust inflation and deflation Manual Must adjust inflation and deflation Can set fixed rate

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Clinical Considerations

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Potential Side Effects and Complications

Limb ischemia Bleeding at the insertion site Thrombocytopenia

Immobility of the balloon catheter

Balloon leak Infection Aortic dissection Compartment syndrome

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Who are prone to Complications

The following patients are at the greatest risk of developing complications associated with IABP: Females, diabetics, smokers, obese patients Patients with PVD, HTN, high SVR, shock

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Limb Ischemia
Assessment Check distal pulses, color, temperature, and capillary refill q30 minutes x 2 hours, then q2 hours Monitor differential toe temperatures Prevention Use smallest sheath/catheter size available Evaluate for risk factors: female, diabetic, PVD Select the limb with the best pulse

Treatment Options Subcutaneous Xylocaine injection for arterial spasm Change insertion site to opposite limb Bypass graft the femoral artery insertion site

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Excessive Bleeding from Insertion Site

Assessment Observe anteriorly and posteriorly for bleeding or hematoma formation

Prevention Employ careful insertion technique Monitor anticoagulation therapy Prevent catheter movement at insertion site
Treatment Options Apply direct pressure at insertion site, assuring distal blood flow Surgical repair of the insertion site
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Thrombocytopenia
Assessment Assess platelet count daily Prevention Avoid excessive heparin administration Treatment Options Replace platelets as needed

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Immobility of the Balloon Catheter

Assessment Observe movement of IAB status indicator Evaluate arterial waveform for diastolic augmentation Prevention Do not allow IAB to be immobile in patient for > 30 min. Maintain an adequate trigger Treatment Options Notify the physician if IAB is immobile for > 30 min. If unable to inflate IAB with the IABP, inflate and deflate IAB by hand, using a syringe and stopcock once every 5 min with 40cc of air or Helium
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Balloon Leak
Assessment Observe helium tubing for blood with or without the presence of a blood detected, low augmentation, gas loss, and/or IAB catheter alarm Prevention Do not remove IAB from T-handle/tray until ready to insert Treatment Options If blood is observed in catheter extender tubing, disconnect IAB from pump.
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Balloon Leak

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Infection
Assessment Observe insertion site for signs of infection Culture blood if symptoms of infection present

Prevention
Use sterile technique during insertion of the IAB catheter Change dressings using sterile technique per infection control policy Treatment Options Antibiotics
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Aortic Dissection
Assessment Assess patient for pain between shoulder blades Monitor hematocrit daily If dissection is suspected, an aortogram may be indicated Prevention Insertion of the IAB over a guidewire with fluoroscopic control Treatment Options Balloon removal Surgical repair of the dissection
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Compartment Syndrome
Assessment

Observe limb for swelling and/or hardness

Measure and record calf girth Monitor interstitial pressure

Prevention
Use smallest catheter/sheath available Maintain adequate colloid osmotic pressure Treatment Options Fasciotomy if necessary
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Weaning of IABP

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 Timing of weaning Patient should be stable for 24 hours. Cardiac output is satisfactory on minimal inotropic support (Dopa/Dobua < 5mics or Epinephrin <1mics) Winning is initiated by decreasing the inflation ratio from 1:1 to 1:2 for about 2-4 hours, then 1:3 or 1:4 for 1-2 more hours. Decrease augmentation Monitor patient closely If patient becomes unstable, weaning should be

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Balloon Catheter Removal

1. Consider tapering or discontinuing anticoagulation therapy prior to removal 2. Stop IAB pumping 3. Disconnect the IAB catheter from the IAB pump permitting the IAB catheter to vent to atmosphere. Patient blood pressure will collapse the balloon membrane for withdrawal. 4. Remove all ties and ligatures 5. If an introducer sheath is used: Loosen the sheath seal from the hub and withdraw the IAB catheter through the introducer sheath until the balloon membrane contacts, but does not enter, the introducer sheath. Do not attempt to withdraw the balloon membrane through the introducer sheath!
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Balloon Catheter Removal.....

6. Remove the IAB catheter and the introducer sheath (if used) as a unit 7. Apply digital pressure below the puncture site during IAB catheter removal. Allow free proximal bleeding for a few seconds, then apply pressure above the puncture site and allow a few seconds of back bleeding. Establish haemostasis by applying pressure to the puncture site. 8. Carefully examine the limb distal to the insertion site for adequate perfusion.

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Some study showing benefit of preoperative use of IABP

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 A 16% reduction of time on cardiopulmonary bypass was achieved when IABP therapy was used preoperatively.
Christenson, JT, et al. Eur J Cardiothorac Surg 1997;11:1097-1103

There was a significant reduction [p<0.0001] in the consumption of dopamine, dobutamine and norepinephrine
Christenson, JT, et al, Todays Therapeutic Trends 1999;17(3):217-225

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 Patients who received preoperative IABP support experienced 34% shorter stays in the intensive care unit (p<0.004).
Christenson, JT, et al. Eur J Cardiothorac Surg 1997;11:1097-1103

Cardiac performance, including cardiac output and cardiac index, was significantly improved in patients who received IABP therapy prior to surgery. There was a 60% reduction in mortality in the IABP group [p<0.05]
Christenson, JT, et al. Eur J Cardiothorac Surg 1997;11:1097-1103

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 The use of preoperative balloon pump therapy in patients undergoing CABG with EF 0.25 Reduced 30-day mortality Shortened the median post-operative hospital stay
Dietl, CA, et al. Efficacy and Cost-Effectiveness of Preoperative IABP in Patients with Ejection Fraction of 0.25 or Less. Ann Thorac Surg 1996;62:401-409

The use of balloon pumping in elderly high risk CABG patients reduced the risk of death and postoperative complications to the level seen in non-high risk patients.
Gutfinger, DE, et al. Aggressive Preoperative use of Intraaortic Balloon Pump in Elderly Patients Undergoing Coronary Artery Bypass Grafting. Ann Thorac Surg 1999; 67:610-613

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In conclusion the use of preoperative balloon pump therapy in high risk patients undergoing CABG
Reduces time on bypass Reduced drug consumption Shortens length of stay in the ICU Reduced cost of hospitalization Lowers in-hospital mortality

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References
Wiegand DJ, Carlson KK; AACN Critical Care Procedures, Performance Evaluation Checklists 3rd Edition. American Association of Critical Care Nurses 2005. Little C; Your guide to the intra-aortic balloon pump. ProQuest Information and Learning Company Springhouse Corporation Dec 2004. Schreuder JJ, Maisano F, Donelli A, Jansen JR, Hanlon P, Bovelander J, Alfieri O; Beat-to-beat effects of intraaortic balloon pump timing on left ventricular performance in patients with low ejection fraction. Annuls of Thoracic Surgery: 2005 Mar;79(3):87280. Linley GH, Bakker EW, de Vroege R, Spijkstra JJ; When the bloodback detection system fails: an IABP case report. Perfusion. 2003 Nov;18(6):369-71. Christenson JT, Badel P, Simonet F, Schmuziger M; Preoperative intraaortic balloon pump enhances cardiac performance and improves the outcome of redo CABG. Annuls of Thoracic Surgery. 2001 Apr;71(4):1400-1. Reference and Educational Materials for Intra-Aortic Balloon 93 Pumping Arrow International. www.arrowintl.com.

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Sequence 1 , Noisy ECG to Pressure

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Sequence 2 , Pressure to ECG

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Sequence 3, Lead fault to Pressure

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