IABP- intra Aortic Balloon Pump

This is a concise presentation on IABP. I tried to cover almost all possible information on IABP.

1. Intra aortic balloon pump Dr. Soham J Shah KEM, Hospital Mumbai

2. Points for discussion : History Principles of IABP function Physiology and Pathophysiology of IABP Indications and Contraindications Anatomy of device Techniques of insertion, complications and removal References Video presentation.

3. ADRIAN KANTROVITZ Started experiments on DIASTOLIC AUGMENTATION at Western Reserve University as a research fellow ( 1952 ) in the Department of Cardiovascular Physiology under Dr.Carl Wiggers .

4. In 1958, Harken : “Removal of some of the blood volume via the femoral artery during systole and replacing it rapidly in diastole, so called diastolic augmentation as a treatment for left ventricular failure.

5. S.MOULOPOULOS & team (1962) At Cleveland clinic , conducted preliminary studies with latex tubing tied around the end of polyethylene catheter with multiple side holes. The tubing,catheter and balloon formed a closed system that was filled with CO2. Stroke was triggered with the aid of ECG.

6. Moulopoulos and colleagues developed a prototype in which IABP inflation and deflation were timed to the cardiac cycle.

7. In 1967 Adrian Kantrowitz after gaining enough experience in animal experiments, He identified that the use of helium as the shuttle gas gave sufficient transit speed to assure appropriate timing. “ On June 29, 1967, 45-year-old woman who was comatose, anuric , cold, and cyanotic , her blood pressure was unobtainable. The patient was clearly near death.“ They inserted the balloon pump and she was pumped for about 7 hours, her condition stabilized, and the pump was removed. The patient recovered and was subsequently discharged from the hospital.

8. Contibutors BUKLEY et al- Balloon inflation in diastole augments coronary perfusion and deflation just before systole markedly reduces resistance to the left ventricular ejection and thereby reduces cardiac work and myocardial o2 consumption. In 1973 two different groups headed by Buckley.M.J & Housman LB , reported the successful utilization of IABP in patients who were unable to be weaned from cardiopulmonary bypass.

9. MUNDTH & coworkers :Reported a patient who sustained cardiogenic shock following myocardial infarction and was stabilised with IABP and subsequently underwent coronary revascularisation with the support of the balloon pump and had an uneventful recovery. This was the first report where the application of the IABP extended successfully to support heart failure post coronary artery surgery.

10. Percutaneous insertion (1980) Bregman D, Casarella WJ. First Percutaneous insertion of intra-aortic balloon pump: Initial clinical experience. Ann Thorac Surg Subramanian VA et al. Preliminary clinical experience with percutaneous intra-aortic balloon pumping . The first prefolded IAB was developed in 1986.

11. 2 IABP Temporary support for the left ventricle by mechanically displacing blood within the aorta Most common and widely available methods of mechanical circulatory support Concepts: Systolic unloading Diastolic augmentation Traditionally used in surgical and non surgical patients with cardiogenic shock

12. Physiological effects of IABP therapy The primary goal of IABP treatment is to improve the ventricular performance of the failing heart by facilitating an increase in myocardial oxygen supply and a decrease in myocardial oxygen demand.

13. IABP inflates at the onset of diastole, thereby increasing diastolic pressure and deflates just before systole, thus reducing LV afterload . Increases coronary perfusion

14. Primary effect of IABP Increase myocardial oxygen supply Decrease myocardial oxygen demand Secondary effect of IABP Increase in cardiac output Increasing in MAP that will lead to improvement of perfusion to all organ Increases LV ejection

15. Effects on other systems Renal = increases renal perfusion and urine output Neurological= increasing cerebral perfusion and enhancing neurological state Vascular- increases peripheral perfusion

16. Basic principles of counterpulsation Counterpulsation (augmentation) is a term that describes balloon inflation in diastole and deflation in early systole. Balloon inflation causes ‘ volume displacement ’ of blood within the aorta, both proximally and distally. This leads to a potential increase in coronary blood flow and potential improvements in systemic perfusion by augmentation of the intrinsic ‘ Windkessel effect

17. 3 Indications for IABP 1. Cardiogenic shock : - Associated with acute MI VSR, Ischaemic MR In association with CABG : Preoperative insertion Patients with severe LV dysfunction Patients with intractable ischemic arrhythmias Postoperative insertion - Postcardiotomy cardiogenic shock 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 VAD Post infarction angina Ventricular arrhythmias relathed to ischemia

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19. CONTRAINDICATIONS Absolute- ▫ Significant aortic regurgitation ▫ Aortic dissection ▫ Aortic stents Relative - ▫ Severe atherosclerosis Abdominal aortic aneurysm ▫ Uncontrolled septicemia ▫ Uncontrolled bleeding diathesis ▫ Severe bilateral peripheral vascular disease

20. Working principles of IABP Balloon pump device Insertion of IABP Position of balloon Effects of IABP Management of IABP Troubleshooting Weaning & Removal

21. 11 The Device

22. THE DEVICE Monitor system

23. 17 Introducer needle Guide wire Vessel dilators Sheath IABP (34 or 40cc) Gas tubing 60-mL syringe Three-way stopcock IABP Kit Contents

24. 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.

25. I ntra Aortic Balloon Catheter

26. Tip

27. 15 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

28. Catheter- 8-9.5 fr Balloon- 25-50ml Membrane-22-27.5cm

29. Insertion 1) Percutaneous insertion via trans Femoral, Axillary , Brachial and Radial approach 2) Femoral artery cutdown insertion 3) Intraoperatively insertion through Ascending aorta ( Transthoracic insertion)

30. Insertion Majority by femoral artery by Seldinger technique Alternatively Ascending aorta Axillary artery Brachial artery Radial artery

31. 18 Connect ECG Set up pressure lines Femoral access – followed by insertion of the supplied sheath IABP insertion

32. 19 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

33. 22 Connecting to console : 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 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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35. POSITION OF IABP The tip should be situated distal to left subclavian artery take off . On chest radiography optimal position will be level of the carina or b/w the 2nd and 3rd intercostal spaces. Too far— subclavian & vertebral occlusion Too low— mesenteric & renal ischemia

36. 1) ECG signal – most common Inflation - middle of T wave Deflation – peak of R wave

37. ECG Pressure wave Internal Pacer V/AV Pacer A

38. Modes of operation

39. The normal IABP blood pressure waveform

40. TIMING

41. The “normal” augmented waveform Increased coronary perfusion

42. How to check waveform is acceptable ?  First change from 1:1 to 1:2 augmentation

43. How to check waveform is acceptable ? Check the dicrotic notch See if augmentation starts at that point This should produce a sharp “V” at inflation . and diastolic augmented wave > Systolic wave.

44. Timing Errors

45. “Balloon too large” syndrome

46. Variation in balloon pressure wave forms Increased duration of plateau due to longer diastolic phase Decreased duration of plateau due to shortened diastolic phase

47. IMP management during IABP

48. Never leave in standby by mode for more than 20 minutes > thrombus formation Patient Management During IABP support

49. Complications Limb ischemia Bleeding at insertion site Infection Aortic dissection – tearing aorta during ballon insertion Thromboembolism

50. Reducing urine output Balloon catheter rupture and gas loss Hemolysis Thrombocytopenia

51. 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 - ABG,Urine output, blood pressure should be good – If patient becomes unstable, weaning should be immediately discontinued

52. Weaning

53. Controversies There has been different schools of thought regarding weaning methods Volume vrs Ratio .. Which is better ? Ratio – reduction in augmention from 1:1 to 1:2 for 4 hours then 1:3 for one hour then removal Volume – 10% of volume reduction every hour for 5 hours then removal.

54. Few papers have published regarding weaning which is better includes Onarati et al (2013) Italy sample size -30 Tokita et.all (2014) USA, sample size- 30 Hsin et al. (2013) Taiwan sample size -85 Bigmani et al. (2012) Italy Lewis et al. (2006) Australia – says Volume weaning is better Manohar et al (2012) USA sample size 429

55. The inference from all above mentioned papers is There has been no clear evidence regarding which method is superior in weaning from IABP still inconclusive.

56. Impella Vrs IABP 1) Impella vrs IABP in acute MI . Brunilda Alushi et.all Germany 2) Impella vrs IABP in acute MI. Abdelmoniem Moustafa et.all USA Impella is asssociated with higher incidence of bleeding, limb compliocations , hemolysis .

57. Video Presentation

58. References Cardiopulmonary bypass priciples and techniques- Amman Jordan Manual of perioperative care in cardiac surgery- Robert M.Bojar Oxford handbook of cardiac surgery Sabiston Spencer book of cardiac surgery IABP: history-evolution pathophysiology indications:what we need to know H. Parissis , V. Graham*et al. A prospective randomized study comparing surgical and percutaneous removal of intraaortic balloon pump Michael J. Rohrer et al. Percutaneous Intraaortic Balloon pumping: Initial Clinical Experience.. David Bregman , M.D., and William J. Casarella , M.D. Intra-aortic balloon pump postcardiac surgery: A literature review Mansour Jannati et al. Intra-aortic balloon pump in CABG – Factors affecting outcome Okonta KE, * Kanagarajan N, Anbarasu M.

59. Thank you.