Intra-aortic Balloon Pump (IABP) By David Kloda

History Realization that coronary perfusion mainly occurs during diastole -1950s Aspiration of arterial blood during systole with reinfusion during diastole decreased cardiac work without compromising coronary perfusion – Harkin-1960s Intravascular volume displacement with latex balloons - early 1960s

Background Preload Afterload Coronary flow Myocardial oxygen consumption in the heart is determined by: Pulse rate Transmural wall stress Intrinsic contractile properties

Myocardial Oxygen Consumption Has a linear relationship to: Systolic wall stress Intraventricular pressure Afterload End diastolic volume Wall thickness

Indications for IABP Cardiac failure after a cardiac surgical procedure Refractory angina despite maximal medical management Perioperative treatment of complications due to myocardial infarction Failed PTCA As a bridge to cardiac transplantation

IABP in Myocardial Infarction and Cardiogenic Shock Improves diastolic flow velocities after angioplasty Allows for additional intervention to be done more safely

IABP During or After Cardiac Surgery Patients who have sustained ventricular damage preoperatively and experience harmful additional ischemia during surgery Some patients begin with relatively normal cardiac function an experienced severe, but reversible, myocardial stunning during the operation

IABP As a Bridge to Cardiac Transplantation 15 to 30 % of endstage cardiomyopathy patients awaiting transplantation need mechanical support May decrease the need for more invasive LVAD support

Other Indications for IABP Prophylactic use prior to cardiac surgery in patients with: Left main disease Unstable angina Poor left ventricular function Severe aortic stenosis

Contraindications to IABP Severe aortic insufficiency Aortic aneurysm

Insertion Techniques Percutaneous sheath less Surgical insertion

Positioning The end of the balloon should be just distal to the takeoff of the left subclavian artery Position should be confirmed by fluoroscopy or chest x-ray

Timing of Counterpulsation Electrocardiographic Arterial pressure tracing

Weaning of IABP Decreasing inotropic support Decreasing pump ratio

Complications Limb ischemia Bleeding and insertion site Thrombosis Emboli Bleeding and insertion site Groin hematomas Aortic perforation and/or dissection Renal failure and bowel ischemia Neurologic complications including paraplegia Heparin induced thrombocytopenia Infection

IABP Removal Discontinue heparin six hours prior Check platelets and coagulation factors Deflate the balloon Apply manual pressure above and below IABP insertion site Remove and alternate pressure to expel any clots Apply constant pressure to the insertion site for a minimum of 30 minutes Check distal pulses frequently

Cardiopulmonary Bypass The heart lung machine The pump The bypass machine

History Concept of diverting the circulation to an extracorporeal oxygenator – 1885 Mechanical pump oxygenators – 1953 Controlled cross circulation – 1954 First series of intracardiac operations using a pump oxygenator – 1955

The Apparatus Pumps Venous reservoir Oxygenator Heat exchanger Other Simple roller pump Centrifugal pump Venous reservoir Oxygenator Heat exchanger Other

Venous Reservoir Siphons blood by gravity Provide storage of excess volume Allows escape of any air bubbles returning with the venous blood

Oxygenator Provides oxygen to the blood Removes carbon dioxide Several types Bubble oxygenator Membrane oxygenator Microporous hollow-fiber oxygenators

Heat Exchanger Also called the heater / cooler Controls perfusate temperature Warm and cold

Cardiopulmonary Bypass Heparinization Total bypass Partial bypass Flowrates 2-2.5 l/min. per square meter Flowrates depend on body size Flowrates depend on cannula sizes Hypothermia

Shed Blood Is aspirated with a suctioning apparatus, filtered and return to the oxygenator A cell saving device may also be utilized during and after bypass

Blood Pressure Decreases sharply with onset of bypass (vasodilatation) Mean arterial pressure needs to the above 50-60 mm Hg. After 30 minutes perfusion pressure usually increases (vasoconstriction)

Oxygen and Carbon Dioxide Tensions Concentrations are periodically measured in both arterial and venous lines Arterial oxygen tension should be above 100 mm Hg Arterial carbon dioxide tensions should be 30-35 mm Hg A drop in venous oxygen saturation suggests underperfusion

Myocardial Protection Cold hyperkalemic solutions Produces myocardial quiescence Decreases metabolic rate Provides protection for 2-3 hours Blood vs. crystalloid

Termination of Perfusion Systemic rewarming Flowrates are decreased Hemodynamic parameters Venous line clamping Pharmacologic support Neutralization of heparin

Complications of Cardio- Pulmonary Bypass Post perfusion syndrome Duration of bypass Age Anemia Other