Intra-aortic balloon counterpulsation is an important supportive tool to the failing heart as a bridge to tide over a temporary crisis.

1. IABP
INTRA-AORTIC BALLOON COUNTERPULSATION
Dr. VISHAL VANANI
JASLOK HOSPITAL AND RESEARCH CENTRE
APRIL 2015

2. HISTORY
 Kantrowitz described
augmentation of coronary blood
flow by retardation of the arterial
pressure pulse in animal models
in 1952.
 In 1958, Harken suggested the
removal of some of the blood
volume via the femoral artery
during systole and replacing it
rapidly in diastole as a treatment
for left ventricular (LV) failure, so
called diastolic augmentation.

3. HISTORY
 In the 1960s, Moulopoulos and
colleagues from the Cleveland Clinic
developed an experimental prototype
of an IABP whose inflation and deflation
were timed to the cardiac cycle.
 In 1968, Kantrowitz reported improved
systemic arterial pressure and urine
output with the use of an IABP in two
subjects with cardiogenic shock, one of
who survived to hospital discharge.

4. HISTORY
 Balloon catheters were 15 French and needed
to be surgically grafted into the femoral arteries.
 Percutaneous IABs in sizes 8.5-9.5 French (rather
than 15 French used earlier) were introduced in
1979, and shortly after this, Bergman and
colleagues described the first percutaneous
insertion of IABP.
 The first prefolded IAB was developed in 1986.

5. CARDIAC PHYSIOLOGY

6. PRELOAD
 Preload refers to the amount of stretch on the
ventricular myocardium prior to contraction.
 Starling’s law described how an increase of volume
in the ventricle at the end of diastole resulted in an
increase in the volume of blood pumped out.
 Preload is often referred to as “filling pressure”.
 Factors affecting preload include:
 Aortic insufficiency
 Circulating blood volume
 Mitral valve disease
 Some medications (i.e. Vasoconstrictors, vasodilators)

7. AFTERLOAD
 Afterload is the resistance that the heart must overcome in
order to eject the blood volume from the left ventricle
 Afterload takes several forms:
 The mass of blood that must be moved, measured by the
hematocrit
 Aortic end diastolic pressure (AEDP).
 Arteriole resistance
 Afterload can be affected by:
 Aortic stenosis
 Arterial vasoconstrictors and vasodilators
 Hypertension
 Peripheral arterial constriction

8. OXYGEN CONSUMPTION
 Myocardial Oxygen Consumption
Depends on
 Systolic wall stress
 Intra-ventricular pressure
 Afterload
 End diastolic volume
 Wall thickness

9. HOW IABP HELPS?

10. IABP – HOW IT WORKS
 A flexibile catheter – into the descending aorta.
 Correct positioning – Important
 When inflated, the balloon blocks 85-90% of the aorta.
 This balloon displaces the blood that is in the aorta.
 This is known as counter pulsation
 This sudden inflation moves blood superiorly and inferiorly
to the balloon.
 When the balloon is suddenly deflated, the pressure
within the aorta drops quickly.

11. WHY HELIUM?
 Helium:
 Low Density
 Soluble

12. IABP – HOW IT HELPS
 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, and the aortic valve is closed.
 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.)

13. IAB INFLATION
 Balloon inflated during
diastole
 Increasing aortic
pressure and
 Increasing coronary
blood flow
 Increases Myocardial
O2 delivery

14. IAB DEFLATED
 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.

15. Hemodynamic Effects of
IABP
Aorta ↓ systolic pressure, ↑ diastolic pressure
Left ventricle
↓ systolic pressure, ↓ end-diastolic pressure,
↓ volume, ↓ wall tension
Heart
↓ Afterload,
↑ Cardiac Output, ↓ O2 Demand
Blood flow ↑ coronary blood flow

16. HEMODYNAMICS :
Summary
 Afterload
 Myocardial oxygen
demand
 Coronary flow
 Cardiac output

17. INDICATIONS
 Refractory unstable angina
 Persistent myocardial
ischemia (preop or postop)
 Acute myocardial infarction
 Complications of acute MI
 Cardiogenic shock
 Refractory LV failure
 Acute MR and VSD
 Support for high-risk
catheterization or failed PCI
 Refractory ventricular
arrhythmias
 As a bridge to cardiac
transplantation
 Support during transport
 Preoperative IABP (high-risk
patients)
 Cardiac surgery, High risk
CABG
 Weaning from
cardiopulmonary bypass
 Postcardiotomy LV systolic
failure unresponsive to
inotropes

18. CONTRAINDICATIONS
 Severe aortic insufficiency
 Dissecting aortic aneurysm
 Descending thoracic aortic
atheroma
 Aorto-iliac-femoral occlusive
disease
 Lower extremity ischemia
 Dynamic LVOTO
 Chronic end-stage heart
disease with no anticipation
of recovery
 Aortic stents
 End-stage cardiomyopathies
 Severe atherosclerosis
 End stage terminal disease
 Abdominal aortic aneurysm
 Uncontrolled sepsis
 Severe peripheral vascular
disease
 Major arterial reconstruction
surgery
 Blood dyscrasias
(Thrombocytopenia)

19. COMPLICATIONS
 Transient loss of peripheral
pulse
 Limb ischaemia
 Thromboembolism
 Compartment syndrome
 Retroperitoneal hematoma
 Local vascular injury—false
aneurysm, haematoma,
bleeding from the wound
 Aortic perforation and/or
dissection
 Cardiac tamponade
 Thrombocytopenia
 Infection / sepsis
 Malpositioning causing
cerebral or renal
compromise
 Renal failure and bowel
ischemia
 Heparin induced
thrombocytopenia
 Balloon rupture (can cause
gas embolus)
 Balloon entrapment

20. HOW TO INTRODUCE

21. 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)

22. IAB Sizing Chart

23. INSERTION TECHNIQUE
 Percutaneous
 Sheath less
 With Sheath
 Surgical insertion
 Femoral cut down
 Trans-thoracic

24.  The IABP device has two major components:
1. A double-lumen 8.0-9.5 French catheter with a 25-50 ml
balloon attached at its distal end; and
2. A console with a pump to drive the balloon.
 The balloon is made of polyethylene and is inflated with
gas driven by the pump.

25. 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

26. HOW TO ADJUST IABP

27. OPERATION MODE

28. OPERATION MODES
Automatic
Tracks cardiac cycle, cardiac rhythm
and adjusts automatically
Semiautomatic
Operator must adjust inflation &
deflation
Manual
Operator must adjust inflation &
deflation & can set fixed rate

29. TRIGGER SOURCE
• During a cardiac arrest, the IABP can
provide very effective perfusion in
conjunction with external compressions.
• Since there is no ECG signal and no arterial
pressure wave to trigger the pump, an
internal trigger is selected.
• This trigger detects the flow of blood caused
by compressions and inflates the balloon
providing improved circulation.
• Good, consistent compressions are a must
for this to work!

30. IAB FREQUENCY

31. AUGMENTATION

32. TIMINGS

33. TIMING OF COUNTER
PULSATION
UASBP UASBP
ADBP
UADBPUADBP
ASBP
DABP

34. INTRAAORTIC BALLOON
COUNTERPULSATION
 Timing of inflation:
• First identify the dicrotic notch (when the aortic valve
closes)
 If inflation is too early the balloon inflates before the
aortic valve closes and pumps blood backwards into
the LV, and ↑ LVEDV & LVEDP, Increased left ventricular
wall stress or afterload, Aortic regurgitation, Increased
MV02 demand.
• If inflation is too late there will be sup-optimal coronary
perfusion

35. INTRAAORTIC BALLOON
COUNTERPULSATION
 Early inflation:

36. INTRAAORTIC BALLOON
COUNTERPULSATION
 Late inflation:

37. INTRAAORTIC BALLOON
COUNTERPULSATION
 Timing of deflation:
• If deflation is too early there will be inadequate afterload
reduction and sub-optimal coronary perfusion
• If deflation is too late the balloon remains inflated too
long, causing ↑ afterload because the heart is trying to
pump against an inflated balloon

38. INTRAAORTIC BALLOON
COUNTERPULSATION
 Early deflation:

39. EARLY DEFLATION
 Waveform Characteristics:
 Assisted aortic end diastolic pressure may be ≤ the
unassisted aortic end diastolic pressure.
 Assisted systolic pressure may rise.
 Physiologic Effects:
 Sub-optimal coronary perfusion.
 Potential for retrograde coronary and carotid blood
flow.
 Sub-optimal after load reduction & Increased MV02
demand.

40. INTRAAORTIC BALLOON
COUNTERPULSATION
 Late deflation:

41. LATE DEFLATION
 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.
 Physiologic Effects:
 Afterload reduction is essentially absent.
 Increased MV02 consumption due to
 The left ventricle ejecting against a greater resistance
 IAB may impede left ventricular ejection and increase
the afterload

42. MAINTENANCE CARE
 Ankle flexion and extension one to two hourly
 Use pressure relieving mattress
 Change ECG electrodes daily.
 Change occlusive dressing daily
 Secure balloon catheter at several points
along the limb.

43. OBSERVATIONS
 Observe hourly at catheter insertion site
 For signs of bleeding
 Signs of infection
 Signs of blood in sheath
 If blood or brown dust is observed within the
lumen, immediately place the IABP on
'Standby'.
 The catheter will have to be removed
immediately.

44. OBSERVATIONS
 Check hourly for left radial pulse
 Put SaO2 probe on left hand
 Assess the limb distal to the insertion
 One hourly Observe and record peripheral
pulses, capillary refill, skin, temperature
 Observe the waveform to ascertain that the
timing is correct

45. 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

46. IABP REMOVAL
 Discontinue heparin six hours prior
 Check platelets and coagulation factors
 Deflate the balloon
 Apply manual pressure above and below IABP
insertion site
 Remove balloon while alternating pressure
above and below insertion site to expel clots
 Apply constant pressure to the insertion site for a
minimum of 30 minutes
 Check distal pulses frequently

47. KEY POINTS
 The primary goal of intra-aortic balloon pump (IABP)
treatment is to increase myocardial oxygen supply and
decrease myocardial oxygen demand.
 Decreased urine output after the insertion of IABP can
occur because of juxta-renal balloon positioning.
 Haemolysis from mechanical damage to red blood cells
can reduce the haematocrit by up to 5%.
 Suboptimal timing of inflation and deflation of the
balloon produces haemodynamic instability.
 An IABP is thrombogenic; always anticoagulate the
patient.
 Never switch the balloon off while in situ.

48. ….THANK YOU….