INTRA AORTIC BALLOON
PUMP (IABP)
Presenter : Dr Rajesh Munigial
DM Trainee
Dept of cardiac anaesthesiology
JNMC, Belgaum
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Topics of discussion
• Introduction
• Mechanism/hemodynamic effects
• Indications
• Contraindications
• Technical aspects
• IABP waveforms
• Complications
• Weaning
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•
What’s new ??
Comparison with other devices 60
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Introduction
• IABP counterpulsation was
introduced by Kantrowitz in the
1960s
• COUNTERPULSATION: describes
balloon inflation in diastole and
deflation in early systole.
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Physiological effects
It also improves RV function by
increasing RV myocardial blood flow
and decreasing left atrial and
pulmonary venous pressures- reduced
RV afterload
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Factors affecting the magnitude of IABP
• Balloon volume
• Heart rate
• Aortic compliance
Stefanidis et al ,1998
• 30% increase in aortic distensibility
• 24% increase in cardiac index
• 31% decrease in myocardial oxygen demand
Coronary artery stenosis : no improvement beyond stenosed territory unless revascularized with
thrombolysis or PCI
Ischemic myocardium is most benefited with systolic offloading than diastolic augmentation thereby
reduced oxygen demand than increased coronary blood flow
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Indications
• Acute congestive heart failure exacerbation with hypotension
• As prophylaxis or adjunct treatment in high-risk PCI
• MI with decreased LVEF leading to hypotension
• MI with cardiogenic shock with acute MR
• Low cardiac output state after cardiac surgery(CABG)
• As a bridge to definitive treatment in patients with any of the following conditions; intractable
angina or myocardial ischemia, refractory heart failure, or intractable ventricular arrhythmias
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It is used for elective placement in high risk patients planned for urgent
cardiac surgery
• Left main disease
• Severe LV dysfunction
• Congestive heart failure
• Cardiomyopathy
• Chronic renal failure
• Cerebrovascular disease
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Difficult CPB separation
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Difficult CPB separation
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Expected changes after IABP insertion in
cardiogenic shock
1. Decrease in SBP by 20%
2. Increase in aortic diastolic pressure by 30%
3. Increase in MAP
4. Reduction in heart rate by 20%
5. Decrease in mean PCWP by 20%
6. Increase in cardiac output by 20%
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Contraindications
• Uncontrolled sepsis
• Uncontrolled bleeding diathesis
• Moderate to severe aortic regurgitation
• An aortic aneurysm or aortic dissection
• Severe peripheral artery disease unless pretreated with stenting
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Guidelines
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• Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A,
D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal
life support in adult patients. J Thorac Cardiovasc Surg. 2021 Apr;161(4):1287-1331. doi:
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10.1016/[Link].2020.09.045. Epub 2020 Oct 7. PMID: 33039139.
TECHNICAL ASPECTS OF IABP
Size of the balloon
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Insertion
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Axillary route 22
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Fibreoptic IABP
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Console
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Too low
Too high
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Waveforms
Waveforms
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IABP Triggers
• ECG
• ARTERIAL WAVEFORM
• PACER V/AV
If patient is 100%paced and ECG causing trigger trouble
• PACER A
If atrial spikes are interfering with R wave detection
• INTERNAL
Manually enter an inflation rate
Used during CPB or VFIB/ASYSTOLE
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Pressure trigger
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TIMING of Inflation and Deflation
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Scenario 1 • Late inflation
• Absence of sharp V
• Suboptimal diastolic augmentation
• Inadequate coronary perfusion
What next ??
Adjust the timing such that balloon
inflates at the dicrotic notch
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Scenario 2
• Early deflation
• Suboptimal diastolic augmentation
• Inadequate coronary perfusion
• Suboptimal afterload reduction
What next ??
Prolong IABP inflation time so that it
deflates at end of diastole or before
onset of isovolumetric systolic
contraction
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Scenario 3
• Early inflation
• Increase LV wall stress
• Increase o2 demand
• Increase workload
What next ??
Delay the onset of IABP inflation
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Scenario 4
• Late deflation
• No afterload reduction
• Instead increase afterload
What next ??
Shorter the inflation time so that
it deflates just before
isovolumetric contraction
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Other waveforms
Kinked balloon • Gas loss
• Rounded balloon waveform • Balloon pressure falls below baseline
• Loose connection or leak in balllon
catheter
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Anticoagulation for IABP
• Routine anticoagulation is not required if IABP triggers 1:1(Kaplan’s)
• No definitive data available
• Institutional protocol to be followed
Current recommendations :
Yin EB. Anticoagulation Management in Temporary Mechanical Circulatory Support
Devices. Tex Heart Inst J. 2023 Jul 19;50(4):e238135. doi: 10.14503/THIJ-23-8135. Erratum
in: Tex Heart Inst J. 2023 Aug 23;50(4):e238292. doi: 10.14503/THIJ-23-8292. PMID: 52
37477030; PMCID: PMC10655856.
Monitoring
• Hourly abdominal girth measurement
• Urine output
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Complications
• Severe bleeding
• Limb ischemia
• Stroke
• Balloon leak or rupture
• Thrombocytopenia
• Haemolysis
• Aortic dissection
• Renal artery, mesenteric artery, or
left subclavian artery obstruction
• Infection/sepsis
• Helium embolism
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Weaning of IABP
• Patient should be stable for 24-48hours
• Decreasing inotropic support
• Decreasing pump ratio 1:1,1:2,1:3,1:4…..
• Decrease augmentation
• If patient becomes unstable weaning should be discontinued
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AXILLARY IABP
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COMPARISON
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References
• Kaplans cardiac anaesthesia perioperative and critical care 8 th edition
• Khan TM, Siddiqui AH. Intra-Aortic Balloon Pump. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2024 Jan
• Tanaka A, Tuladhar SM, Onsager D, Asfaw Z, Ota T, Juricek C, Lahart M, Lonchyna VA, Kim G, Fedson S, Sayer G, Uriel N,
Jeevanandam V. The Subclavian Intraaortic Balloon Pump: A Compelling Bridge Device for Advanced Heart Failure. Ann Thorac
Surg. 2015 Dec;100(6):2151-7; discussion 2157-8. doi: 10.1016/[Link].2015.05.087. Epub 2015 Jul 28. PMID: 26228596.
• Murli Krishna, Kai Zacharowski,Principles of intra-aortic balloon pump counterpulsation,Continuing Education in Anaesthesia
Critical Care & Pain,Volume 9, Issue 1,2009,Pages 24-28
• Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020
EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg. 2021 Jan
4;59(1):12-53. doi: 10.1093/ejcts/ezaa283. PMID: 33026084.
• Yin EB. Anticoagulation Management in Temporary Mechanical Circulatory Support Devices. Tex Heart Inst J. 2023 Jul
19;50(4):e238135. doi: 10.14503/THIJ-23-8135. Erratum in: Tex Heart Inst J. 2023 Aug 23;50(4):e238292. doi: 10.14503/THIJ-
23-8292. PMID: 37477030; PMCID: PMC10655856.
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THANK YOU !!! 61