Dharam Prakash Saran

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Intra aortic balloon counter pulsation( IABP):

Most common and widely available methods of mechanical circulatory support

Temporary support for the left ventricle by mechanically displacing blood within the aorta

Concepts: - Systolic unloading- Diastolic augmentation

Traditionally used in surgical and non surgical patients with cardiogenic shock

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Indications for IABP

1. Cardiogenic shock:

2. In association with CABG :

Preoperative insertion- Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias

Postoperative insertion - Postcardiotomy cardiogenic shock

- Associated with acute MI - Mechanical complications of MI - MR , VSD

3. In association with nonsurgical revascularization:

-Hemodynamically unstable infarct patients-High risk coronary interventions

- severe LV dysfunction, LMCA, complex coronary artery disease

4. Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia

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CONTRAINDICATIONSAbsolute-

▫ Significant aortic regurgitation▫ Aortic dissection▫ Aortic stents▫ Bilateral femoral popliteal bypass grafts for severe

PVD

Relative -▫ Abdominal aortic aneurysm▫ Uncontrolled septicemia▫ Uncontrolled bleeding diathesis▫ Severe bilateral peripheral vascular disease

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Interpreting IABP waveforms

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IABP –instrumentation and techniques

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The IAB Counter pulsation system- two principal parts

A flexible catheter -2 lumen • first - for distal aspiration/flushing or pressure monitoring • second - for the periodic delivery and removal of helium gas to a

closed balloon.

A mobile console • system for helium transfer • computer for control of the inflation and deflation cycle

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Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20 %

- Increase in aortic Diastolic Press. by 30 % ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20%

-Decrease in the mean PCWP by 20 %

- Elevation in the COP by 20%

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IABP catheter:

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85% of aorta occluded (not 100%)

The shaft of the balloon catheter contains 2 lumens: - one allows for gas exchange from console to

balloon- second lumen

- for catheter delivery over a guide wire - for monitoring of central aortic pressure

after installation.

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Intra Aortic Balloon

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Balloon sizing

Sizing based on patients height

Four common balloon sizes

Balloon length and diameter increases with each larger size

40 cm³ balloon is most commonly used

Paediatric balloons also available : sizes 2.5, 5.0, 12.0 and 20 cm³

Balloon size Height

50 cm³ > 6 feet

40 cm³ 5 feet 4 inch

to 6 feet

34 cm³ 5 feet to 5

feet 4 inch

25 cm³ < 5 feet

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Benefits of larger volume IABs• More blood volume displacement• More diastolic augmentation• More systolic unloading

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

IABP Kit Contents

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Connect ECG

Set up pressure lines

Femoral access – followed by insertion of the supplied sheath

0.030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

- IABP insertion

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Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray.)

Pull out the T- handle only as shown

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• Remove stylet/aspirate/Flush

• Insert the balloon only over the guide wire

• Hold the catheter close to skin insertion point

• Advance in small steps of 1 to 2 cm at a time and stop if any resistance.

• The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD, or dissection

- Kinking of IABP » improper inflation/deflation

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- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

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Connecting to console: - Connect helium gas tube to the console via a long extender - Open helium tank.

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure.

- Zero the transducer

Initial set-up:- Once connected properly the console would show ECG and pressure

waveforms.- Check Basal mean pressure- Make sure the setting is at “auto”- Usually IABP started at 1:1 or 1:2 augmentation- Usually Augmentation is kept at maxim

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Trigger modesTrigger :

- Event the pump uses to identify the onset of cardiac cycle (systole)- Pump must have consistent trigger in order to provide patient assist- If selected trigger not detected, counter pulsation will interrupted

1.ECG- uses the slope of QR segment to detect triggering point

2. AP(Arterial pressure wave)- Systolic upstroke of the arterial pressure wave form is the trigger

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ECG signal – most common• Inflation

- middle of T wave• Deflation

– peak of R wave

• Pacer (v/a)

• Arterial waveform

• An intrinsic pump rate (VF, CPB)

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Increased coronaryperfusion

The “normal” augmented waveform

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Not all Sub optimal augmentation is due to Timing errors/kinks

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Factors affecting diastolic augmentation

Patient- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

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How to check waveform is acceptable ?

First change from 1:1 to 1:2 augmentation Check the dicrotic notch See if augmentation starts at that point

This should produce a sharp “V” at inflation.

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How to check waveform is acceptable ?

First change from 1:1 to 1:2 augmentation Check the dicrotic notch See if augmentation starts at that point

This should produce a sharp “V” at inflation. Check if diastolic augmented wave is › systolic wave

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How to check waveform is acceptable ?

First change from 1:1 to 1:2 augmentation Check the dicrotic notch See if augmentation starts at that point

This should produce a sharp “V” at inflation. Check if diastolic augmented wave is › systolic wave

Confirm if end diastolic wavefollowing the augmented wave is less than an non augmented wave.

Is Deflation slope ok

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Late Inflation Inflation of the IAB markedly after closure of the aortic valve.Waveform Characteristics:

• Inflation of IAB after the dicrotic notch.• Absence of sharp V.• Sub optimal diastolic augmentation

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Early Deflation Premature deflation of the IAB during the diastolic phase.

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Late Deflation Late deflation of the IAB during the diastolic phase.

Waveform Characteristics:• Assisted aortic end diastolic pressure may be equal to the

unassisted aortic end diastolic pressure.• Rate of rise of assisted systole is prolonged.• Diastolic augmentation may appear widened

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Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

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Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

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Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

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Variation in balloon pressure wave forms

Gas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline..

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas

diffusion through the IAB membrane

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Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or

obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow

inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

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“Balloon too large”

syndrome

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Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily – to R/O IAB migration

Check lower limb pulses - 2 hourly. - If not palpable » ? - vascular obstruction

- thrombus, embolus, or dissection (urgent surgical consultation)

Prophylactic antibiotics NOT INDICATED

Hip flexion is restricted, and the head of the bed should not beelevated beyond 30°.

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Never leave in standby by mode for more than 20 minutes > thrombus formation

Daily– Haemoglobin (risk of bleeding or haemolysis)– Platelet count (risk of thrombocytopenia) – Renal function (risk of acute kidney injury secondary to distal

migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associatedwith higher incidence of limb complications

Patient Management During IABP support

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Weaning of IABP

Timing of weaning:

- Patient should be stable for 12 – 24 hours- Decrease inotropic support- Decrease pump ratio

– From 1:1 to 1:2 or 1:3- Decrease augmentation- Monitor patient closely

– If patient becomes unstable, weaning should beimmediately discontinued

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IABP Removal

-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met.

- NEVER attempt to withdraw the balloon membrane through the introducer sheath.

-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved.

ACC/AHA 2013Practice Guidelines (ESC

2012- IIb)

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ESC 2014 GUIDELINES

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IABP IN UA/NSTEMI (2007, 2012

update)

(Current Practices)(Class IIa LOE-©)

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The placement of an IABP could be useful in patients with recurrent ischemia despite maximal medical management and in those with hemodynamic instability until coronary angiography and revascularization can be completed.

TRIALS OF IABP

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Benchmark registry

• n = 17,000( june 1996- aug 2000)

• 203 hospitals- 90% US

• 18.8% of IABP used for cardiogenic shock

• Device related death – 0.5%

• Major complication – 2.6%

• Minor complication – 4.2%

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Balloon-pump assisted Coronary Intervention

Study (BCIS-1):

• The first randomized controlled trial of elective

Intra-Aortic Balloon Pump (IABP) insertion prior to

high-risk PCI vs. PCI with no planned IABP use

• 17 UK centres

• n=301 (150 in each arm)

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58IABP in high risk PCI(BCIS-1 TRIAL)

N= 301 Elective IABP(

151)

No elective

IABP(150)

P VALUE

MACE 15.2% 16% 0.85

All cause mortality

at 6 mths

4.6% 7.4% 0.32

Major procedural

complications

1.3% 10.7% <0.001

Major or minor

bleeding

19.2% 11.3% 0.06

Access site

complications

3.3% 0% 0.06

Patients (n = 301) had severe left ventricular dysfunction (ejection fraction ≤ 30%) and extensive coronary disease (Jeopardy Score ≥ 8/12); those with contraindications to or class I indications for IABP therapy were excluded

JAMA. 2010;304(8):867-874

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Conclusions of long term results of

BCIS1 trial(2012-2013)

In patients with severe ischemic cardiomyopathy treated

with PCI, all cause-mortality was 33% at 51 months

(median)

Elective IABP use during PCI was associated with an

observed 34% reduction in long-term all-cause mortality

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Counterpulsation Reduces Infarct Size Acute Myocardial Infarction (CRISP AMI) trial.

Intra-aortic balloon pump counterpulsation prior to PCI in patients with ST segment elevation MI without shock does not reduce infarct size as measured by MRI

Shock trial and registry

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N-302 pts

N- 152 pts N- 150 pts

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SHOCK Trial

Primary and Secondary Endpoints

0

20

40

60

80

30 Days 6 months

Immediate

Revascularization

Strategy

Medical Stabilization

as an Initial Strategy

Primary Endpoint

Secondary Endpoint

Mo

rta

lity

(%

)

46.7%

56.0% 50.3

%

63.1%

P=.11

P= .027

Hochman et al, NEJM 1999; 341:625.

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Impact of thrombolysis, intra-aortic balloonpump counterpulsation, and theircombination in cardiogenic shockcomplicating acute myocardial infarction: areport from the SHOCK Trial Registry

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SHOCK Registry: Impact of Thrombolytics and IABP

0

20

40

60

80

47%

52%%

P<0.0001

63%

77%

Thrombolytics

+ IABP

No Thrombolytics

+ IABP

Thrombolytics

+ No IABP

Neither

Hochman et al, NEJM 1999; 341:625.

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Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock

IABP Shock II Trial

Conclusion

• The use of intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned.

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MCQs

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• 1. Major physiological effects of counter pulsation include?

▫ A) increased coronary artery perfusion, increased preload, decreased after load, decreased myocardial oxygen consumption

▫ B) increased coronary artery perfusion, increased preload, increased after load, decreased myocardial oxygen consumption

▫ C) increased coronary artery perfusion, decreased preload,

decreased after load, increased myocardial oxygen consumption

▫ D) increased coronary artery perfusion, decreased preload, decreased after load, decreased myocardial oxygen consumption

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2. The dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

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3. Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except?

A) Decrease in SBP by 20 %

B) Increase in aortic DP by 30 %

C) Decrease in MAP by 10%

D) Reduction of the HR by 20%

E)Decrease in the mean PCWP by 20 %

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4. late inflation of the balloon can result in?

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

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5. A rounded balloon pressure wave form indicate?

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

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6. width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

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7. true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of isovolumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

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8. true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50% paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

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9. Identify the tracing abnormality

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10. Identify the tracing abnormality

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• 1. Major physiological effects of counter pulsation include?

▫ A) increased coronary artery perfusion, increased preload, decreased after load, decreased myocardial oxygen consumption

▫ B) increased coronary artery perfusion, increased preload, increased after load, decreased myocardial oxygen consumption

▫ C) increased coronary artery perfusion, decreased preload,

decreased after load, increased myocardial oxygen consumption

▫ D) increased coronary artery perfusion, decreased preload, decreased after load, decreased myocardial oxygen consumption

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2. the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

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3. Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except?

•A) Decrease in SBP by 20 %

•B) Increase in aortic DP by 30 %

•C) Decrease in MAP by 10%

•D) Reduction of the HR by 20%

•E)Decrease in the mean PCWP by 20 %

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4. late inflation of the balloon can result in?

• A) premature augmentation

• B) increased augmentation

• C) decreased augmentation

• D) increased coronary perfusion

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5. A rounded balloon pressure wave form indicate?

• A) helium leak

• B) power failure

• C) hypovolemia

• D) balloon occluding the aorta

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6. width of balloon pressure wave form corresponds to

• A) length of systole

• B) length of diastole

• C) arterial pressure

• D) helium level

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7. true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of isovolumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

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8. true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50% paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press. Wave form

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9.

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10.

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