INTRA-AORTIC BALLOON PUMP by Nick Mark MD ONE onepagericu.

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PRINCIPLE:
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Intra-aortic balloon counter-pulsation is a method of invasive hemodynamic support. UNASSISTED ECG electrodes are
A catheter is placed through an arterial sheath and advanced into the thoracic aorta. IABP ASSISTED Radio-opaque tip
AORTIC used to trigger inflation
A gas filled balloon at the end of the catheter inflates in sync with the cardiac cycle: VALVE should be ~2cm distal
CLOSES
· Balloon inflates in diastole ! increases coronary perfusion LVSP = Systolic BP to the left subclavian
· Balloon deflates in systole ! decreases afterload & increases LV stroke volume (SV) AORTIC
The thick-walled LV is only perfused by the coronaries during diastole. By increasing Stroke volume is VALVE
increased with A 25-50 ml aortic

LV pressure
diastolic pressure, the IABP improves coronary artery perfusion. OPENS
IABP support balloon fills 85-
Intra-aortic balloon pumps (IABP) can be used to support people in cardiogenic 90% of the
SV
shock, those undergoing revascularization, or as a bridge to to intervention or for Stroke work (area
thoracic aorta
interfacility transport. It can also be used as an LV vent in patients receiving VA ECMO. of the PV curve) is
similar
While ithas salubrious hemodynamic effects, neither RCTs nor meta-analysis has LVEDP

found a survival benefit to IABP use in people with cardiogenic shock. Balloon should be proximal
to the renal arteries
TRIGGER:
LV volume
Proper IABP support depends on precise inflation & deflation timing. In order to sync 7.5Fr Sheath is placed in artery
the balloon with the cardiac cycles, the controller uses EKG or aortic pressure to AUGMENTATION/WEANING: & allows balloon catheter
catheter
trigger inflation. Asynchronous (e.g. set at a rate of 80) can be used as a backup. The level of hemodynamic support can be adjusted. to be advanced to the aorta
· EKG: triggers inflation at the middle of the T-wave & triggers deflation at the peak of By default, the IABP augments every cycle (1:1). It
the R wave. Arrythmias such as afib & pacer spikes can disrupt EKG triggering. (Atrial can be decreased to every other (1:2) or every third Sterile sleeve permits
pacing is particularly problematic). ECG triggering is preferable in most patients. (1:3) cycle. Timing & adjustments should be done in adjusting the depth of
· Pressure: aortic pressure triggers inflation at the dicrotic notch and deflates based 1:2 mode. Decreasing support (1:1 ! 1:2 ! 1:3) is the intra-aortic balloon
elapsed time. Pressure trigger is inherently less precise than EKG (the pressure wave often done to wean IABP, though the actual
propagates slower than electricity) coronary perfusion provided in 1:3 may be minimal.

TIMING: The controller unit rapidly Sheath side port

UNASSISTED ASSISTED UNASSISTED inflates the intra-aortic balloon can be used for
Ideally the balloon would inflate immediately at the onset of
diastole (40 msec before the dicrotic notch). Modern IABP have just after aortic valve closure blood draws
automatic timing but timing can (& should be) manually optimized. Pressure transducer
EKG

Consequences of improper timing include: & pressure bag used

· Early balloon inflation !increased afterload to measure pressure
· Late balloon inflation ! decreased diastolic augmentation Augmented diastolic pressure is within the aorta.
· Early balloon deflation ! no decrease in myocardial O2 demand Unassisted systolic increased by balloon inflation Some newer IABP
· Late balloon deflation ! increases afterload systems use a
Aortic Pressure

· Poor diastolic augmentation ! suboptimal coronary perfusion Assisted systolic fiberoptic sensor to
Timing should always be adjusted in 1:2 support mode. pressure is decreased measure pressure
ANTICOAGULATION: changes more rapidly.
The catheter is potentially thrombogenic, however based on
limited data, routine anticoagulation may not be required in 1:1

v1.0 (2022-05-05) CC BY-SA 3.0

mode. It may be necessary if augmentation is reduced to 1:2, 1:3. Unassisted diastolic
Assisted diastolic pressure Helium tank
A sharp V morphology
COMPLICATIONS & MONITORING: decreased by balloon deflation Helium is used because it has
Balloon Pressure

at the dicrotic notch

· Limb ischemia ! monitor distal pulses HELIUM
lower airflow resistance, which
indicates optimal timing
· Juxta-renal positioning ! monitor urine output, CXR enables faster balloon inflation
· Bleeding, hematoma ! monitor sheath site, check coags & deflation. Helium is also
· Decreased augmentation ! consider low SVR (sepsis), Balloon highly soluble in blood, so it is
decreased cardiac output (AIBP requires a CI of >1 to “augment”) inflation IABP 1:2 AUGMENTATION
less likely to cause air embolism
· Worsening cardiac ischemia ! adjust timing/trigger if the balloon ruptures.