Intra-aortic balloon counterpulsation (IABC) involves inserting a balloon into the aorta that inflates during diastole and deflates during systole to assist the heart. It works by increasing diastolic pressure and coronary blood flow while reducing systolic pressure and ventricular workload. IABC is used for reversible heart failure and as a bridge to transplantation. Risks include limb ischemia, infection, and embolism. Timing of balloon inflation and deflation is critical for effectiveness.
Intra-aortic balloon counterpulsation (IABC) involves inserting a balloon into the aorta that inflates during diastole and deflates during systole to assist the heart. It works by increasing diastolic pressure and coronary blood flow while reducing systolic pressure and ventricular workload. IABC is used for reversible heart failure and as a bridge to transplantation. Risks include limb ischemia, infection, and embolism. Timing of balloon inflation and deflation is critical for effectiveness.
Intra-aortic balloon counterpulsation (IABC) involves inserting a balloon into the aorta that inflates during diastole and deflates during systole to assist the heart. It works by increasing diastolic pressure and coronary blood flow while reducing systolic pressure and ventricular workload. IABC is used for reversible heart failure and as a bridge to transplantation. Risks include limb ischemia, infection, and embolism. Timing of balloon inflation and deflation is critical for effectiveness.
Dr N. Seetaramji Registrar, Dept. Of Anaesthesiology, Wockhardt Hospital. History
Willem Kolff, Stephen Topaz, et al
conceived this procedure at the Cleveland Clinic in 1961 Kantrowitz applied it to patients in 1967. JAMA 203:135, 1968 Concepts of Counterpulsation The balloon is phasically pulsed in counterpulsation to the patient’s cardiac cycle (IABC) IABP has no ‘inotropic’ action; does not directly increase contractility. Primarily benefits the left ventricle, although the diastolic augmentation may improve coronary flow to both ventricals. Some Basics of Myocardial O2 Supply/Delivery Ischemic heart has maximally dilated arteries. Perfusion is then directly related to perfusion pressure. Coronary perfusion occurs predominately during diastole Increasing diastolic time increases coronary blood flow Major resistance to (subendocardial) coronary blood flow during diastole is LVEDP such that... CPP=AoDP-LVEDP AoDP and LVEDP are dynamic values Windkessel Effect Contd. Overlapping the aortic pressure and LV pressure curves gives a visual representation of the pressure gradient. This gradient over the diastolic time cycle is described as the Diastolic Pressure Time Index (DPTI) Area within the DPTI is directly correlated with O2 availability to the myocardium (supply) Some Basics of MVO2/Demand
HR, contractility, wall tension (50% of MVO2 at rest).
Laplace’s law T=Pr/2h Intraventricular pressure is a modifiable variable. IVP greatest during systole (LVSP). LVSP is a dynamic value continually changing throughout systole and altering wall tension as this occurs. Area under the LVSP tracing is represented by the Tension Time Index (TTI) and is directly correllated to wall tension and MVO2. Contd. Increasing systole time (HR) or peak LV systolic pressure increases the TTI and subsequently MVO2 Conversely, lowering the AoEDP (decreased afterload) decreases the pressure the LV must overcome to eject blood and lowers the TTI The Endocardial Viability Ratio relates the relationship between myocardial O2 supply and demand and is defined by EVR=DPTI/TTI (supply/demand). Windkessel Effect Potential energy stored in aortic root during systole Converted to kinetic energy with elastic recoil of aortic root Increases diastolic pressure/flow during early diastole Less affect with hypovolemia or noncompliant aortas Noted on the A-line tracing as the dicrotic notch IABP- how does it work? IABP does not ‘pump’ blood per se in contrast to a VAD. Requires a functioning, beating heart. IABP serves as an external source of energy to allow the sick heart to pump more efficiently. Does this via afterload reduction and diastolic augmentation. Net result is an increased DO2, decreased MVO2, and an increased CO. Indications Pump failure (reversible) - AMI ; Ohman EM et al (1994), Kono T et al (1996). (JACC Guidelines 1996 on IABP use in AMI) - cardiogenic shock -progressive deterioration despite pharmacologic support - Reversible mech. effects -VSD, Ac. Mitral Regurgitation. - Unstable Angina / PTCA. Contd. Cardiac transplant patient -as a bridge to transplantation -post transplant support Prophylactic preoperative use Aide to separate from CPB Transport to tertiary centre. Post traumatic Heart Failure. Supporting High Risk Non-Cardiac Surgery. Contraindications
> 1.8 40 262 Placement. 6.5 Fr Catheter, 8 Fr Introducer, Heparinisation, etc. If Pulses not felt, Ankle arm index. Placed percutaneously or surgically with or without a sheath via the femoral artery; Seldinger technique. Advanced into aorta under flouroscopy until the tip is about 2 cm distal to the origin of the left subclavian artery. Catheter locations more proximal than this compromise flow to the vessels of the aortic arch. More distal locations attenuate the hemodynamic benefits of the IABP and can potentially compromise renal blood flow. Contd.
Palpate the Left Radial artery pulse.
Confirm position with X’ray Chest/TEE. Keep aPTT @ twice control. Check circulation to the relevent limb: Doppler ankle pressure < 40 mmHg / ankle arm index < 0.25 indicate circulatory impairement. Follow Sr Creatinine & urine output daily Compartment syndrome, watch for. Determinants of IABP efficiency Ideal balloon volume causes maximal emptying of LV without causing retrograde flow from the coronary vasculature and vessels of the aortic arch. Balloon should occlude 75-90% of the aortic cross- sectional area during inflation. CO2 vs Helium Efficiency if IABC is critically dependent on the timing of both inflation and deflation. IAPB Triggering IABP requires a trigger to determine systole and diastole. ECG or arterial waveform. ECG directly from the patient to the pump or the pump can slave off the bedside monitor. T-wave default. Electrical index of diastole. Deflation occurs prior to the next QRS (during PR interval). Timing is manually fine-tuned according to the aortic pressure waveform (more representative of mechanical events). External Pacemaker – Danger ?/Emergency use. Internal impulse generation from console Early inflation: Aortic valve still open, ↑Ventricular Workload. Late Inflation: ↓rise in diastolic aortic root pressure, ineffective coronary perfusion. Early Deflation: shortens diastole, ↓coronary perfusion time Late Deflation: balloon still inflated, ↑ ventricular afterload. IAB monitors self Volume & pressure in the balloon. Leaks in driving gas. Loss of ECG/Arterial signal Arrhythmia detection & change in Heart rate. Improper deflation of the IAB. Limitations of IABC
Heart Rate, 130/min ?
Arrhythmias (non-sinus rhythms) Hypovolemia Systolic pressure: 40 mmHg for pressure trigger. Cardiac Output: Minimum CI of 1.2 to 1.4 ltrs/min/m2. Diastolic Augmentation Balloon inflation at the onset of diastole which is correllated to aortic valve closure (mechanical event). Displacement of blood within the aorta to areas proximal and distal to the balloon. Termed “compartmentilization”. Proximal compartment consists of branches of aortic arch (carotids) and coronary vasculature. Diastolic balloon inflation augments cerebral and coronary perfusion. Increased DPTI and EVR. ‘Exaggerated’ Windkessel Effect. Afterload Reduction Optimal balloon deflation occurs just prior to the opening of the aortic valve; during early isovolemic contraction. Abruptly decreases intraaortic volume AoEDP is acutely decreased (afterload reduction). AoV opens sooner during cardiac cycle lending more time for ventricular ejection Overall result is a larger SV (CO). A lower peak LVSP decreases the TTI which leads to a decrease MVO2 and an icrease in the EVR. BP & IABP Normal BP has two reference points- SBP & DBP With a pump set at 1:2 you have 5 different reference points. Net effect: *SBP following an augmented beat will be lower than SBP following an unassisted beat. *AoEDP following an augmented beat will be lower than AoEDP following an unassisted beat. *Peak diastolic augmented pressure will be integrated into the pressure reading on the arterial line. Overall BP as read by A-line (number you see) should increase BP & IABP Weaning
Frequency ratio weaning (1:1, 1:2, 1:3,
etc.). Volume weaning (more physiologic?)
Stop Heparin 2 hrs & Platelet count
> 60,000/mm3 before IAB explantation.
Risk of IABC Reported complication rates vary, but in general range about 20-30% of all IABP’s placed. Factors which predispose to a higher complication rate include age, pre-existing vascular disease, duration of IABP, DM, HTN, obesity, and vasopressor therapy. Complications : During Insertion Failure: 6%, even with 8Fr sheath. Arterial dissection, perforation. Bleeding Misplacement to LV, Subclavian, Lt. common carotid, contralateral Femoral arteries were reported. Isner JM (1980) Complications: Balloon in situ Limb Ischemia/compartment syndrome Infection Thrombocytopenia/hemolytic anemia Embolization of platelet aggregates Rupture of balloon/gas embolism IAB Entrapment complications with Size ≥ 9.5 Fr and balloon in situ for > 48 hrs. Complications: After Removal