Intra-arterial balloon

pump: a primer & some

evidence
Andrea Tsai
September 24, 2019

Tremper RS. Intra-aortic balloon pump therapy--a primer for perioperative nurses. AORN J. 2006;84(1):34-44.
 IABP Nuts and Bolts
● Double lumen catheter
○ Inner lumen transduces
○ Outer lumen inflates / deflates balloon
● Size varies based on patient height
○ 8 - 9.5 Fr Balloon
Height (cm)
○ Balloon diameter Volume (ml)
< 80-90% < 152 (60”) 25
descending 152 - 163 (60” - 64”) 34
thoracic aorta 163 - 183 (64” - 72”) 40
diameter > 183 (72”) 50

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Where do I stick you in, IABP?
Vascular Surgical*:
(percutaneous): ● Transthoracic
● Femoral ● Translumbar
● Brachial ● Iliac
● Subclavian
● Axillary

*Increased periprocedural
mortality

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 A. here? B. here?
IABP:
where do
you live?
C. here?

D. here?

http://commons.wikimedia.org/wiki/File:Aorta_scheme_noTags.svg
 B: IABP ideally lives between the
subclavian and the celiac
● 2-3 cm distal to subclavian
○ TEE or fluoroscopic guidance
○ CXR landmarks: proximal tip at
■ Lower aspect of the aortic knob
■ 2nd intercostal space anteriorly
■ Carina
● Try not to cover important things
○ Patients with IABPs + CTs:
■ Celiac artery covered 96.8%
■ SMA covered 87.3%
■ Renal arteries covered 66.6%
http://ca.maquet.com/images/gallery_sensation_2.jpg
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Rastan AJ, et al. Visceral arterial compromise during intra-aortic balloon counterpulsation therapy. Circulation. 2010;122(11 Suppl):S92-9.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Correct position on CXR does not
always mean correct position

Rastan AJ, et al. Visceral arterial compromise during intra-aortic balloon counterpulsation therapy. Circulation. 2010;122(11 Suppl):S92-9.
 IABP runs on helium
Helium (Carbon dioxide)
● Low density = more ● Easily absorbed into
laminar & lower blood stream in case
resistance of balloon rupture
● Easily absorbed into ● Not really used
blood stream in case anymore, but I guess
of balloon rupture you could

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Balloon inflates during diastole
● Displaces blood
proximally and distally
● Increases coronary artery
perfusion*
○ Increases RV & LV oxygen
Heart supply*
● Increases systemic
perfusion*

*That’s the idea anyways

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Balloon deflates during early systole
● Decreases LV afterload
○ Thereby decreasing RV
afterload*
● Decreases myocardial
oxygen demand*
Heart ● Increases cardiac output
by +0.5 Lpm*

*That’s the idea anyways

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Hemodynamic Effects of IABP

*(no change in CO has also been observed)

Effects depend on:

● Balloon volume: mo volume = mo blood displaced
● Heart rate:
○ Diastole time inversely proportional to HR
○ Less diastole = less balloon augmentation
● Aortic compliance: mo compliance (or less SVR) = less
diastolic augmentation
Ishihara M, et al. Effects of intraaortic balloon pumping on coronary hemodynamics after coronary angioplasty in patients with acute myocardial infarction. Am
Heart J. 1992;124(5):1133-8.
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Papaioannou TG, et al. Basic principles of the intraaortic balloon pump and mechanisms affecting its performance. ASAIO J. 2005;51(3):296-300.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Metabolic Effects of IABP
“The reverse
changes or no
change may also be
observed,
depending upon
various other
clinical or technical
factors.”

Papaioannou TG, et al. Basic principles of the intraaortic balloon pump and mechanisms affecting its performance. ASAIO J. 2005;51(3):296-300.
 Hematologic effects of IABP
● ↓Hemoglobin
○ Hemolysis from mechanical damage
○ Bleeding from vascular access site
○ Average Hgb/Hct decrease 2.3 / 5.7%
according to a trial from the 1970s
● ↓Platelets
○ Mechanical destruction
○ Heparin administration

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Anticoagulation:
Heparin gtt, PTT 50-70
● RCT: 71 with heparin, 82 without
○ No difference in incidence of limb ischemia
○ More bleeding with heparin
● Observational study: 102 universally
heparinized, 150 selectively heparinized (53% of
these received heparin):
○ Only difference is less “major non-access site
bleeding” in selective heparin group
○ “Among CCU patients undergoing IABP, a selective
heparin strategy appears to be superior to a strategy
of universal heparin use”
Cooper HA, et al. The role of heparin anticoagulation during intra-aortic balloon counterpulsation in the coronary care unit. Acute Card Care. 2008;10(4):214-20.
Jiang CY, et al. Anticoagulation therapy in intra-aortic balloon counterpulsation: does IABP really need anti-coagulation? J Zhejiang Univ Sci. 2003;4(5):607-11.
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Immobile IABP is highly
thrombogenic
● Planned IABP removal:
○ Discontinue heparin 2-6h prior to removal
○ Keep IABP running at least 1:8 until removal
■ Tufts CCU - 1:1 if no heparin
● Unplanned IABP immobility (e.g., balloon
rupture)
○ Remove quickly (within 30 minutes)

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP: Patient considerations

● Bedrest while IABP in place and for 6

hours after removal

Good! Less good.

http://img.medscape.com/article/762/378/762378-fig9.jpg
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Indications & Contraindications
Absolute
Cardiogenic shock
- Aortic regurgitation
● Refractory LV failure
- Aortic dissection
● Acute MR & VSD
- Aortic stents
● Cardiomyopathies
- Chronic end-stage heart
Perfusion of CAD - Sepsis disease with no anticipation of
● Acute MI - Arrhythmias recovery
● Refractory unstable ← ventricular
angina tachy → Relative
● Catheterization &
- Abdominal aortic aneurysm
angioplasty
- Severe PVD
Cardiac surgery
- Major arterial reconstruction
● Weaning from CPB
surgery
● Pedi + complex cardiac
- Coagulopathy
anomalies

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Complications
● Vascular Risk factors for badness
○ Bleeding (0.8%)
○ Systemic embolization ● Age > 75
○ Limb ischemia (0.9%) ● PVD
○ Amputation (0.1%)
● Infection ● DM
● Mechanical complications ● Female
○ Balloon rupture
○ Inadequate inflation ● Small BSA (<1.65)
● Death (0.05%)
○ Aortic dissection
○ Aortic rupture

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP
Patient
Assessment

http://ca.maquet.com/file_assets/educationa
l-materials/en/Quick-Reference-Guide-IAB-I
nsertion-CS300-Operation-EN.pdf
IABP Triggering & Waveforms!

ALL OF US ARE SMARTER

THAN ANY OF US!
Where is the start of systole?
Where is the start of diastole?
Great! Now, what does the
A-line do relative to this?

Systole Systole Systole

Awesome! Now, what happens
at the dicrotic notch?

Systole Systole Systole

 Hooray! Now you know how to
trigger an IABP!*
Balloon deflation** Balloon inflation
● Systole ● Diastole
● ECG: mid-R to mid-T ● ECG: mid-T to mid-R
● A-line: just before ● A-line: dicrotic notch
systolic arterial to just before systolic
upstroke to dicrotic arterial upstroke
notch

*Can also trigger by pacemaker or preset internal rate

** Timing controversial
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 Normally functioning IABP Waveform (1:2):
● Peak augmented diastolic pressure should
be higher than unassisted SBP
○ Increased coronary perfusion
● Assisted SBP and DBP should be lower
than their respective unassisted values
○ Decreased afterload

Eval in 1:2
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems
Too Early Too Late

Inflation

Deflation

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems
Too Early Too Late

Inflation X

Deflation

● IABP inflates before AV

closure
● LV empties against
inflated balloon
○ Increased afterload
○ Increase myocardial
O2 demand?
○ Worse systolic
function?

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems
Too Early Too Late

Inflation X

Deflation

● Minimal diastolic
augmentation

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems
Too Early Too Late

Inflation

Deflation X

● Shorter period of
diastolic augmentation
● Decreased aortic
pressure may promote
retrograde flow
○ Cerebral ischemia?
○ Myocardial
ischemia?
● Generally, optimal
deflation = ↓ assisted
Hanlon-Pena PM, et al. Intra-aortic balloon pump timing: review of evidence supporting current
practice. Am J Crit Care. 2011;20(4):323-33.
DP and ↓ assisted SP
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth
Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems

Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 IABP Triggering Problems
Too Early Too Late

Inflation

Deflation X

● LV empties against
inflated balloon
○ Increased afterload
○ Increase
myocardial O2
demand?
○ Worse systolic
function?
● Generally, optimal
deflation = ↓ assisted
DP and ↓ assisted SP
Hanlon-Pena PM, et al. Intra-aortic balloon pump timing: review of evidence supporting current practice. Am J Crit Care. 2011;20(4):323-33.
Murli K, et al. Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain. 2009;9(1):24-28.
Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391-8.
 “Maximizing inflation time & LV
unloading cannot be done
simultaneously”
● Maximize cardiac perfusion → maximize
diastolic augmentation
○ Later deflation
● Optimize ventricular unloading and
reduce cardiac work → minimize end
diastolic pressure
○ Earlier deflation

Hanlon-Pena PM, et al. Intra-aortic balloon pump timing: review of evidence supporting current practice. Am J Crit Care. 2011;20(4):323-33.
IABP Console
IABP Console

Settings for the

coding patient?
IABP Display
 IABP for MI + Cardiogenic Shock
Cochrane Review (2011)
● “Available evidence suggests that IABP may have a
beneficial effect on the haemodynamics, however there
is no convincing randomized data to support the use of
IABP in infarct related cardiogenic shock”
IABP-SHOCK II (2012, 2013)
● “[IABP] did not significantly reduce 30-day mortality in
patients with cardiogenic shock complicating acute
myocardial infarction for whom an early
revascularization strategy was planned”
● “IABP did not reduce 12 month all-cause mortality”
Thiele H, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-96.
Thiele H, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of
a randomised, open-label trial. Lancet. 2013;382(9905):1638-45.
Unverzagt S, et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev.
2011;(7):CD007398.
ICU quick & dirty: pump failure
● 1 inotrope
● 2 inotropes
● IABP: adds ~0.5 Lpm CO, perc
● Impella CP: 3.5 Lpm CO max, perc
● Impella 5.0: 5.0 Lpm CO max, needs
axillary cut down for placement
● ECMO: 5-7 Lpm CO + pulm support, perc
● Centrimag: 5-9 Lpm CO, needs CTSg for
placement, can be +/- pulm support
 IABP-SHOCK II Design
● Randomized, prospective, open-label,
multicenter trial
● 600 patients with cardiogenic shock
complicating acute MI
○ IABP group: 301
○ Control (no IABP): 299
● Early revascularization (PCI or CABG) + best
available medical therapy
● Primary end point: 30-day all-cause
mortality
Thiele H, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-96.
Thiele H, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of
a randomised, open-label trial. Lancet. 2013;382(9905):1638-45.
 IABP-SHOCK II Results
● 30d mortality: IABP 119 (39.7%), control 123 (41.3%)
○ RR 0.96 (95% CI, 0.79-1.17; P = 0.69)
● 12M mortality: IABP 155 (52%), control 152 (51%)
○ RR 1.01 (95% CI, 0.86-1.18, P = 0.91)
● No difference in 2° endpoints:
○ Time to hemodynamic stabilization
○ ICU LOS
○ Lactate
○ Dose & duration of catecholamine therapy
○ Renal function
● No difference in adverse events (IABP v. control):
○ Major bleeding (3.3% v. 4.4%; P = 0.51)
○ Peripheral ischemic complications (4.3% v. 3.4%, P = 0.53)
○ Sepsis (15.7% v. 20.5%, P = 0.15)
○ Stroke (0.7% and 1.7%, P = 0.28)
Thiele H, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-96.
Thiele H, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of
a randomised, open-label trial. Lancet. 2013;382(9905):1638-45.
 IABP did not reduce 12-month
all cause mortality

Thiele H, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-96.
Thiele H, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of
a randomised, open-label trial. Lancet. 2013;382(9905):1638-45.
 Subgroup analysis is hypothesis generating

Thiele H, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-96.
Thiele H, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of
a randomised, open-label trial. Lancet. 2013;382(9905):1638-45.
 Study limitations:
● No blinding
● Lower mortality
(→ less severe
shock?)
● Crossover

Thiele H, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-96.
Thiele H, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of
a randomised, open-label trial. Lancet. 2013;382(9905):1638-45.
THE
END!
YAY!
Questions?
 Deflation timing is controversial

(Conventional deflation occurs completely within diastole; essentially means early-ish deflation)

(Real time deflation essentially means later-ish deflation)

Hanlon-Pena PM, et al. Intra-aortic balloon pump timing: review of evidence supporting current practice. Am J Crit Care. 2011;20(4):323-33.
 IABP (105) v. control (40) or
percutaneous LVAD (45): all-cause
30d mortality distribution

Unverzagt S, et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev.
2011;(7):CD007398.
 Cochrane Review (cont’d)
● No difference in in-hospital all cause mortality
○ IABP: 32/83 (39%)
○ Control: 27/64 (42%)
○ OR 0.88, 95% CI 0.44 to 1.76
● No difference in 6M all cause mortality
○ IABP: 20/42 (48%)
○ Control: 21/41 (51%)
○ Hazard ratio of 0.93, 95% CI 0.49 to 1.77
● No difference in 1 year all cause mortality
○ IABP: 9/16 (56%)
○ Control: 6 /16 (38%)
○ OR 2.14, 95% CI 0.52 to 8.81
Unverzagt S, et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev.
2011;(7):CD007398.
 Cochrane Review (cont’d)

Unverzagt S, et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev.
2011;(7):CD007398.
 IABP: similar complication rates
compared with no intervention, less
compared with LVAD
Compared with no intervention:
● No difference in bleeding (0%)
● No difference in limb or leg ischemia (3.2%)
Compared with percutaneous LVAD:
● Decreased bleeding, 14.9% v. 50.9%, OR 0.12
(0.04-0.36)
● Decreased limb or leg ischemia, 4.3% v. 22.6%, OR 0.28
(0.06-1.34)
● No difference in infection 31.9% v. 32.1%
● No difference in thrombocytopenia, 8.8% v. 10%

Unverzagt S, et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev.
2011;(7):CD007398.
http://upload.wikimedia.org/wikipedia/commons/thumb/f/f4/Wiggers_Diagram.svg/1098px-Wiggers_Diagram.svg.png
 IABP for CABG preop
Cochrane Review (2011)
● “Preoperative IABP may have a beneficial effect on
mortality and morbidity in specific high risk patient
groups undergoing CABG, however there are many
problems with the quality, validity and generalisability
of the trials...the available evidence is not robust enough
to extend the use of IABP to truly elective, high risk
patients”
SCORE (2013)
● “Patients undergoing nonemergent coronary operations,
with a stable hemodynamic profile and a LVEF < 35%,
the preincision insertion of IABP does not result in a
better outcome.”
Ranucci M, et al. A randomized controlled trial of preoperative intra-aortic balloon pump in coronary patients with poor left ventricular function undergoing coronary artery bypass surgery. Crit Care
Med. 2013;41(11):2476-83.
Theologou T, et al. Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting. Cochrane Database Syst Rev. 2011;(1):CD004472.
 IABP v. Impella for high-risk PCI
● 452 symptomatic patients randomized to IABP
(226) or Impella 2.5 (226) during nonemergent
PCI
○ Complex 3v disease or unprotected left main disease
○ Severely depressed LVEF
● No difference in 30-day incidence of major
adverse events
● Trend for improved outcomes were observed for
Impella 2.5–supported patients at 90 days

O'Neill WW, et al. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing
high-risk percutaneous coronary intervention: the PROTECT II study. Circulation. 2012;126(14):1717-27.
http://ca.maquet.com/file_assets/educational-materials/en/IAB-Sizing-Card-EN.pdf