text book reading stase Cathlab - IABP.pptx

ppt

1. Textbook Reading: INTRAAORTIC BALLOON PUMP ( IABP ) Presentator : dr. Irma Sihotang Pembimbing : Prof. dr. Harris Hasan, Sp.PD , Sp.JP (K) Departemen Kardiologi dan Kedokteran Vaskular FK USU/RSUP H.Adam Malik Divisi Invasif dan Intervensi Non Bedah

2. FIGURE : Determining whether hemodynamic support is needed and optimal device selection

3. INTRODUCTION Four devices are currently available in the US for providing percutaneous left ventricular hemodynamic support: The intraaortic balloon pump ( IABP ), the Impella the Tandem Heart veno -arterial extracorporeal membrane oxygenator (VA-ECMO) LEFT VENTRICULAR HEMODYNAMIC SUPPORT In preshock patients (cardiac index . 2.0 L/min/ m2 ), use of IABP may suffice, although continuous hemodynamic monitoring, ideally with a Swan Ganz catheter, is needed to determine the need for escalating support. In shock patients with isolated severe LV failure the Impella CP device is most commonly used. In patients with LV failure and refractory shock (continued hypoperfusion) despite Impella CP or Tandem Heart use, escalation to VA-ECMO or Impella 5.0 may be required. The Impella is often left in place to provide left ventricular unloading (LV venting) during VA-ECMO support.

4. FIGURE : Devices that provide left ventricular hemodynamic support. Protec Duo

5. IABP The IABP was first used clinically in CS by Kantrowitz in 1968. Intraaortic balloon pump ( IABP ) is the smallest device but also supplies the least hemodynamic support. IABP is usually inserted percutaneously through a 7 – 8 French femoral arterial sheath. The IABP mechanism of action is : inflation of a balloon with helium in the aorta during diastole, increasing coronary perfusion, displacing blood peripherally and increasing cardiac output, while reducing left ventricular end-diastolic pressure and reducing afterload. INTRODUCTION

6. CONCEPTS: SYSTOLIC UNLOADING DIASTOLIC AUGMENTATION

7. Augmentation of diastolic pressure Increase coronary perfusion Increase myocardial oxygen supply IAB Inflation - Diastole Decrease afterload Decrease cardiac work Decrease myocardial oxygen consumption Increase cardiac output IAB Deflation - Systole

8. INDICATIONs :

9. IABP Insertion: Step by Step

10. Obtain femoral access Goal ? : Safely obtain arterial access to insert the IABP How ?: The femoral sheath is provided with the IABP kit.

11. Prepare IABP for Use Select IABP size Attach one-way valve to the gas lumen (do not remove until IABP is in position in the aorta). Use the provided syringe to apply vacuum off the IABP helium lumen. The syringe is then removed, while keeping the one-way valve in place. Remove the IABP catheter from the tray (immediately prior to insertion). Remove stylet from IABP catheter wire lumen. Flush IABP wire lumen with normal saline. Connect fiber-optic cable to the console and zero fluid transducer.

12. Advance guidewire and IABP catheter to aortic arch Goal : Advance IABP guidewire (0.025 inch, provided in the IABP kit), over which the IABP will be inserted. How ? IABP wire is advanced under fluoroscopy to the aortic arch. Position : The end the balloon should be just distal ( 1-2 cm ) to the takeoff of the left subclavian artery and confirmed by fluoroscopy or chest x-ray. Goal : Advance IABP catheter to optimal position. How ? The IABP is advanced under fluoroscopy until the tip of the catheter is at the level of the tracheal bifurcation.

13. Start IABP function Goal : Initiate IABP function. How ? 1. The guidewire is removed and the wire lumen is connected to an arterial pressure monitoring system. 2. The helium port is connected with the IABP console. 3. Counterpulsation is initiated

14. Monitor IABP function Goal : Ensure IABP optimal functioning. How ? Use 1:2 augmentation and ensure that timing of balloon inflation is optimal. Monitor systemic pressure Monitor IABP position. Ensure therapeutic anticoagulation is administered. If anticoagulation cannot be administered, 1:1 augmentation should be used to minimize the risk of thrombus formation on the IABP balloon.

15. I A B P (1) (4) (3) (2)

16. Figure : Mechanical setup of the intra-aortic balloon pump ( IABP )

17. Challenges: Challenges Causes Prevention Treatment Poor augmentation (mean pressure not increasing) Hypovolemia. Low balloon position. Small size balloon for the patient’s aorta. Low systemic vascular resistance. Improper timing. Kinked catheter. IABP delivered volume is too low. Optimal IABP size selection and placement in the aorta, as well as optimal inflation volume and timing. Treat underlying causes Poor afterload reduction Balloon not inflated to full volume. Compliant aortic wall. Improper balloon position. Partial obstruction of gas lumen. Improper timing. Optimal IABP size selection, optimal placement, optimal inflation timing and optimal inflation volume. Treat underlying causes IABP migration Catheter inadvertently pulled back Suture IABP after insertion. Reposition and then secure IABP catheter.

18. What can go wrong?? : Access site complications, including limb ischemia and retroperitoneal bleeding . Causes : Suboptimal access technique, Anticoagulation. Prevention: Optimal access technique Treatment : Tailored to the type of complication : an ischemic limb will usually recover after removing the IABP and its sheath with manual hemostasis, however it may sometimes require surgical or endovascular treatment; retroperitoneal bleeding may require cessation of anticoagulation. If the anticoagulation is discontinued during IABP use, 1:1 augmentation should be used to minimize the risk of thrombus formation on the IABP . 2. Aortic dissection . 3. Thromboembolism ( due to thrombus formation on the IABP ). 4. IABP catheter entrapment

19. Complications

20. Removal of the IABP can occur if there is continued clinical stability after a period of observation on 1:4 counterpulsation . Step by step to remove an IABP : T he operator discontinues anticoagulation and places the pump on a 1:4 or 1:8 counterpulsation ratio to prevent clot formation. After administration of local anesthetic, the catheter is disconnected from the console and suction is applied with a syringe to collapse the balloon. Once inflated, the IABP balloon retains a high profile and cannot be withdrawn through the sheath. Removal requires that the balloon catheter and sheath are removed together as one unit. Because small clots may form on the balloon catheter and potentially occlude the femoral artery, the puncture site is allowed to bleed freely for a second or two to help expel any thrombus inadvertently dragged into the access site. Hemostasis is achieved by manual compression of the arteriotomy site for 30 to 60 minutes, and a sterile dressing is applied. The patient should remain at bed rest for several hours to prevent rebleeding. Removal of IABP :

21. Contraindication Contraindications for IABP : 1. Severe aortic regurgitation. 2. Aortic dissection. 3. Uncontrolled bleeding (although IABP can be used without anticoagulation for a short period of time in patients with active bleeding).

22. Thank You