Intra-Aortic Balloon Pump (IABP)

By
Imran Yousafzai
Lecturer, KMU
Back-Ground
• Realization that coronary
perfusion mainly occurs during
diastole -1950s
• Aspiration of arterial blood
during systole with reinfusion
during diastole decreased
cardiac work without
compromising coronary
perfusion – Harkin-1960s
• Intravascular volume
displacement with latex
balloons - early 1960s
 Intra-aortic balloon pump (IABP)
• The Intra-aortic balloon pump (IABP) is a mechanical
device that is used to decrease myocardial oxygen
demand while at the same time increasing cardiac
output. By increasing cardiac output it also increases
coronary blood flow and therefore myocardial oxygen
delivery. It consists of a cylindrical balloon that sits in
the aorta and counter-pulsates. That is, it actively
deflates in systole increasing forward blood flow by
reducing afterload thus, and actively inflates in diastole
increasing blood flow to the coronary arteries. These
actions have the combined result of decreasing
myocardial oxygen demand and increasing myocardial
oxygen supply.
 Hemodynamics
• Helium is rapidly pumped into and out of the balloon
(about 40ccs). When inflated, this balloon displaces
the blood that is in the aorta.
– This is known as counter pulsation
– Helium is used because it is a soluble gas and will not
cause an embolus if the balloon ruptures
• This sudden inflation moves blood superiorly and
inferiorly to the balloon.
• When the balloon is suddenly deflated, the pressure
within the aorta drops quickly.
 Hemodynamics (cont.)
• Inflation of the balloon occurs at the onset of diastole. At that
point, maximum aortic blood volume is available for
displacement because the left ventricle has just finished
contracting and is beginning to relax, the aortic valve is
closed, and the blood has not had an opportunity to flow
systemically.
• The pressure wave that is created by inflation forces blood
superiorly into the coronary arteries.
– This helps perfuse the heart.
• Blood is also forced inferiorly increasing perfusion to distal
organs (brain, kidneys, tissues, etc.)
 Hemodynamics (cont.)
• The balloon remains inflated throughout diastole.
• At the onset of systole, the balloon is rapidly
deflated. The sudden loss of aortic pressure caused
by the deflation reduces afterload.
– The left ventricle does not have to generate as much
pressure to achieve ejection since the blood has been
forced from the aorta.
– This lower ejection pressure reduces the amount of work
the heart has to do resulting in lower myocardial oxygen
demand.
 Preload
Preload is defined as the amount of blood
volume or pressure in the left ventricle at the
end of diastole (i.e. the resting phase of the
heart). Factors affecting preload include:
aortic insufficiency
circulating blood volume
mitral valve disease
some medications (i.e. vasoconstrictors, vasodilators)
 Afterload
Afterload is the resistance that the heart must
overcome in order to eject the blood volume
from the left ventricle. Afterload can be affected
by:
aortic valvular stenosis
arterial vasoconstrictors and vasodilators
hypertension
peripheral arterial constriction
 Myocardial Oxygen Consumption
• Has a linear relationship to:
– Intraventricular pressure
– Afterload
– End diastolic volume
– Wall thickness
 Background Summary
• Preload (slight decrease)
• Afterload (decreases)
• Coronary flow (increases)
• Myocardial oxygen (decreases)
• Cardiac output (increases)
IABP Summary Table
 Indications for IABP
• Cardiac failure after a cardiac surgical procedure
• Refractory angina despite maximal medical
management
• Cardiogenic shock
• Mitral regurgitation
• Perioperative treatment of complications due to
myocardial infarction
• Failed PTCA
• As a bridge to cardiac transplantation
 IABP During or After Cardiac Surgery
• Patients who have sustained ventricular
damage preoperatively and experience
harmful additional ischemia during surgery
• Some patients begin with relatively normal
cardiac function an experienced severe, but
reversible, myocardial stunning during the
operation
 IABP As a Bridge to Cardiac
Transplantation
• 15 to 30 % of endstage cardiomyopathy
patients awaiting transplantation need
mechanical support
• May decrease the need for more invasive
LVAD support
 Contraindications to IABP
• Severe aortic insufficiency
• Aortic aneurysm
• Aortic dissection
• Limb ischemia
• Thromboembolism
 IABP Kit Contents
• Introducer needle
• Guide wire
• Vessel dilators
• Sheath
• IABP (34 or 40cc)
• Gas tubing
• 60-mL syringe
• Three-way stopcock
• Arterial pressure tubing (not in kit)
 Insertion Techniques
• Percutaneous
– Sheath less
• Surgical insertion
– Femoral cut down
– Trans-thoracic
 Positioning
• The end of the balloon should be just distal to
the takeoff of the left subclavian artery
• Position should be confirmed by fluoroscopy
or chest x-ray
 Timing of Counterpulsation
• Electrocardiographic
• Arterial pressure tracing
 IABP Timing Frequency
• Arterial pressure waveforms
 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
 Troubleshooting in the OR
• ECG trigger may not be functioning properly
– Check slave cable connections
– Check patient leads
– Change ECG lead source
• Autofill may fail
– Check helium and refill, then check balloon
• Balloon may not augment CO adequately
– Check balloon position
– Reposition balloon is necessary
 Complications
• Limb ischemia
– Thrombosis
– Emboli
• Bleeding and insertion site
– Groin hematomas
• Aortic perforation and/or dissection
• Renal failure and bowel ischemia
• Neurologic complications including paraplegia
• Heparin induced thrombocytopenia
• Infection
 Weaning of IABP
• Timing of weaning
– Patient should be stable for 24-48 hours
• Decreasing inotropic support
• Decreasing pump ratio
– From 1:1 to 1:2 or 1:3
• Decrease augmentation
• Monitor patient closely
– If patient becomes unstable, weaning should be
immediately discontinued
Weaning should only be attempted on order of a physician.
 IAB Removal
• Discontinue heparin six hours prior
• Check platelets and coagulation factors
• Deflate the balloon
• Apply manual pressure above and below IABP insertion site
• Remove and alternate pressure to expel any clots
• Apply constant pressure to the insertion site for a minimum of
30 minutes
• Check distal pulses frequently

IAB should only be pulled by a physician or the cardiac P.A.