Intra-Aortic Balloon Pump Counterpulsation

Iskander Al-Githmi, MD, FRCSC

Assistant Professor of Surgery

King Abdulaziz University

Historical Perspective

• 1958- Harken: Described the diastolic augmentation and counterpulsation to treat LV failure

• 1962-Moulopoulus: From Cleveland clinic, developed an experimental (IAB) whose inflation and deflation were timed to cardiac cycle

• 1968-Kantrowitz: Introduce the (IAB) to the clinical practice in patient with post-infarction cardiogenic shock

Intra-Aortic Pump Catherter

Physiologic effect of IABP

• Reduction of left ventricular afterload

• Increase aortic root pressure and coronary perfusion

• Decrease myocardial oxygen demand

Coronary Artery Flow Autoregulation

• Flow=Pressure/ resistnce

Indications:

• Cardiogenic shock or pump failure

• Unstable angina

• Failure to wean patient off CPB Prophylaxis:

• High grade left main coronary stenosis

• Post infarction acute mitral regurgitation and septal defect

Contraindications:

• Severe aortic regurgitation

• Aortic dissection

• Severe peripheral vascular disease

• Non-salvageable patient- Irreversible brain injury

Arterial Waveform

IABP Arterial Waveform

IAB catheter insertion technique

• Seldinger technique

• Cut-down

Timing

Balloon pressure waveform

1.zero baseline2.Fill pressure baseline3.IAB inflation4.Pressure artifact/positive overshoot5.Plateau pressure (IAB inflated)6.IAB deflation7.Vaccum artifact/negative overshoot8.Return to baseline (IAB deflated)

Timing Basics

• To patient arterial waveform (always)

• To patient EKG signal

Timing problems

• Early inflation

Timing Problems

• Early deflation

Timing Problem

• Late deflation

Triggering

• Trigger on the R wave- preferred method

• Good quality EKG signal and lead i.e unidirectional QRS complex, R wave is taller than P and T waves also it has adequate amplitude

Triggering

Good Lead

Triggering

• QRS complex cause wandering timing

Complications

• Limb ischemia (10-25%)• Balloon rupture• Thrombosis within the balloon • Infection • Bleeding• False aneurysm • Femoral neuropathy• Lymphocele

Questions

Question1

Asses the timing in the following strip

a. Correct Timingb. Early inflation and late deflationc. Early inflation and early deflationd. Correct inflation and early deflatione. Late inflation and early deflation

Question 2

What is wrong with the arterial pressure line

a. AP line is dampenedb. Transducer need to zerodc. The IBP is too high and the tip of art.line is being occluded as it hit the archd. Nothing e. There is air in the pressure tubing

Question 3

Asses the timing in the following strip

a. Early inflation and early deflationb. Late inflation and late deflationc. Correct inflation and late deflationd. Late inflation and early deflatione. Correct timing

The pump is the peak trigger mode ,what part of the EKG complex is being recognized as the trigger event?

a. The R wave

b. The pacer spike

c. The arterial pressure waveform

d. The T wave

e. No trigger is seen

Question 5

The indications for IABP therapy include:a. Cardiogenic shock following acute myocarditis

b. Acute mitral regurgitation with pulmonary edema from papillary muscle rupture

c. Acute VSD following myocardial infarction

d. Acute aortic regurgitation from edocarditis