Intra-Aortic Balloon Pump Counterpulsation

1. Intra-Aortic Balloon Pump Counterpulsation Iskander Al-Githmi, MD, FRCSC Assistant Professor of Surgery King Abdulaziz University

2. 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

3. Intra-Aortic Pump Catherter

4. Physiologic effect of IABP • Reduction of left ventricular afterload • Increase aortic root pressure and coronary perfusion • Decrease myocardial oxygen demand

5. Coronary Artery Flow Autoregulation • Flow=Pressure/ resistnce

6. 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

7. Contraindications: • Severe aortic regurgitation • Aortic dissection • Severe peripheral vascular disease • Non-salvageable patient- Irreversible brain injury

8. Arterial Waveform

9. IABP Arterial Waveform

10. IAB catheter insertion technique • Seldinger technique • Cut-down

11. Timing

12. Balloon pressure waveform 1.zero baseline 2.Fill pressure baseline 3.IAB inflation 4.Pressure artifact/positive overshoot 5.Plateau pressure (IAB inflated) 6.IAB deflation 7.Vaccum artifact/negative overshoot 8.Return to baseline (IAB deflated)

13. Timing Basics • To patient arterial waveform (always) • To patient EKG signal

14. Timing problems • Early inflation

15. Timing Problems • Early deflation

16. Timing Problem • Late deflation

17. 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

18. Triggering Good Lead

19. Triggering • QRS complex cause wandering timing

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

21. Questions

22. Question1 Asses the timing in the following strip • Correct Timing • Early inflation and late deflation • Early inflation and early deflation • Correct inflation and early deflation • Late inflation and early deflation

23. Question 2 What is wrong with the arterial pressure line • AP line is dampened • Transducer need to zerod • The IBP is too high and the tip of art.line is being occluded as it hit the arch • Nothing • There is air in the pressure tubing

24. Question 3 Asses the timing in the following strip • Early inflation and early deflation • Late inflation and late deflation • Correct inflation and late deflation • Late inflation and early deflation • Correct timing

25. The pump is the peak trigger mode ,what part of the EKG complex is being recognized as the trigger event? • The R wave • The pacer spike • The arterial pressure waveform • The T wave • No trigger is seen

26. Question 5 The indications for IABP therapy include: • Cardiogenic shock following acute myocarditis • Acute mitral regurgitation with pulmonary edema from papillary muscle rupture • Acute VSD following myocardial infarction • Acute aortic regurgitation from edocarditis